Malaysian Registry of Intensive Care...Malaysian Registry of Intensive Care Report for 2014 Prepared...

Malaysian Registry of Intensive Care

Report for 2014

Prepared by

Dato’ Dr Jenny Tong May Geok

Dr Tai Li Ling

Dr Tan Cheng Cheng

Dr As-Niza Abdul Shukor

Dr Lim Chew Har

Dr Laila Kamaliah bt Kamalul Bahrin

Technical Committee of the Malaysian Registry of Intensive Care

June 2015

© Malaysian Registry of Intensive Care

Published by:

Malaysian Registry of Intensive Care

Clinical Research Centre

Ministry of Health Malaysia

Disclaimer:

This work may be reproduced in whole or part for study or training purposes, subject to the

inclusion of an acknowledgement of the source.

Suggested citation:

Jenny Tong May Geok, Tai Li Ling, Tan Cheng Cheng, As-Niza Abdul Shukor, Lim Chew Har,

Laila Kamaliah bt Kamalul Bahrin

Malaysian Registry of Intensive Care 2014 report

Electronic version:

This report can be downloaded at MRIC website: www.mric.org.my

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CONTENTS Page

Contents……………………………………………………………………………………. 4

Report Summary…………………………………………………………………………... 5

Acknowledgement………………………………………………………………………… 6

Foreword…………………………………………………………………………………… 7

MRIC Technical Committee 2014………………………………………………………. 8

Participating Hospitals…………………………………………………………………… 9

Categories of ICU …………………………………………………………………………. 11

Site Investigators and Source Data Providers 2014…..………………………………… 13

Abbreviations……………………………………………………………………………… 17

List of Tables………………………………………………………………………………. 18

List of Figures……………………………………………………………………………… 19

Introduction……………………………………………………………………………….. 20

Results

Section A General Information…………………………………………………… 22

Section B Patient Characteristics………………………………………………… 33

Section C Interventions…………………………………………………………… 56

Section D Complications…………………………………………………………. 69

Section E Mortality Outcomes…………………………………………………... 84

Section F Quality Improvement activities……………………………………… 92

Section G Dengue infection 2010 – 2014………………………………………… 102

Summary……………………………………………………………………………………. 107

References…………………………………………………………………………………… 109

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REPORT SUMMARY

This is the report on all intensive care admissions to the 51 participating centres from 1st January to

31st December 2014.

The following are the main findings: 1. The total number of ICU beds in the 49 MOH participating units was 637 with a median

bed occupancy rate of 90.5%.

2. The number of cases analysed was 38,904, an increase of 4% over the previous year. 3. The percentage of patients denied admission due to the unavailability of ICU beds had

declined from 37% to 30% in the last five years. 4. The average age of the patients, excluding those below 18 years, was 49.7 years.

5. The average duration of ICU and hospital stay was 4.7 and 14.2 days respectively.

6. In MOH hospitals, 68% of ICU admissions were non-operative patients.

7. Direct admissions to MOH ICUs from the emergency department had increased more than three-fold over the past 10 years from 10% in 2005 to 31% in 2014.

8. Dengue infection, sepsis and head injury were the three most common diagnoses leading to ICU admission in MOH hospitals in 2014. The in-hospital mortality rates for this group of patients were 7.1%, 52.8% and 22.2%respectively.

9. The average SAPS II score was 36.3, which carries a predicted in-hospital mortality of 30.4%.

10. In MOH hospitals, 74% of patients received invasive ventilation with an average duration of 4.9 days.

11. The percentage of patients who received non-invasive ventilation increased more than three-fold from 5.1% in 2005 to 18.6% in 2014.

12. The incidence of ventilator-associated pneumonia in MOH ICUs had decreased by more than half, from 10.1 to 3.6 per 1000 ventilator days, in the last five years.

13. The incidence of central venous catheter-related bloodstream infection in MOH ICUs was 0.8 and 0.7 per 1000 catheter days for 2013 and 2014 respectively

14. The crude in-ICU and in-hospital mortality rates for MOH hospitals were 19.0% and 25.7%

respectively. 15. The crude in-ICU and in-hospital mortality rates for UMMC were 18.4% and 25.8%

respectively.

16. The mean standardised mortality ratio was 0.69 [95%C.I. 0.48–0.95], 0.65 [95%C.I.0.44 – 0.90] and 0.22 [95%C.I. 0.11–0.59] for MOH, UMMC and SJMC ICUs respectively.

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ACKNOWLEDGEMENT The Technical Committee of the Malaysian Registry of Intensive Care would like to thank the following: All site investigators and source data providers The heads of Department of Anaesthesia and Intensive Care of participating ICUs Staff of the participating ICUs Quality of Health Care Unit, Medical Development Division, Ministry of Health National Clinical Research Centre, Ministry of Health Health Informatics Centre, Ministry of Health Malaysian Society of Intensive Care All who have contributed in one way or another to the MRIC

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FOREWORD

It is a privilege for me to be writing this foreword for the MRIC report of 2014. This registry has been ongoing for more than a decade and the data obtained has been a reference source for the Ministry of Health for the continuous improvement in the delivery of critical care services to patients. This report highlights all intensive care admissions to the 51 participating centres from 1st January to 31st December 2014. The number of cases analysed was 4% higher over the previous year. Dengue infection, sepsis and head injury were the three most common diagnoses leading to ICU admission in MOH hospitals. The incidence of ventilator-associated pneumonia in MOH ICUs had decreased by more than half, in the last five years. The incidence of central venous catheter-related bloodstream infection was 0.7 per 1000 catheter days in 2014. This is heartening to note that this rate is within the set standard of the Malaysian Patient Safety Goals indicators. I see a challenging future ahead for the further development of intensive care services in Malaysia especially with the increased awareness and demand by the public, newer challenges with emerging infectious diseases and increasing antibiotic resistance. I take this opportunity to thank Dato’ Dr Jenny Tong May Geok, Dr Tai Li Ling, Dr Tan Cheng Cheng, Dr As-Niza Abdul Shukor, Dr Lim Chew Har and Dr Laila Kamaliah for working together to produce this report. I want to acknowledge the hard work of all the site investigators and source data collectors who have contributed to the registry. I also want to express my thanks to the National Clinical Research Centre and Medical Development Division, Ministry of Health for their continued guidance and support.

Dr. Sivasakthi V Head of the Anaesthesia and Intensive Care Services Ministry of Health Malaysia

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TECHNICAL COMMITTEE MALAYSIAN REGISTRY OF INTENSIVE CARE 2014

Advisors Datin Dr Sivasakthi Velayuthapillai

Consultant Anaesthesiologist and Head Department of Anaesthesia and Intensive Care Hospital Kuala Lumpur

Principal Investigator Dato’ Dr Jenny Tong May Geok Consultant Anaesthesiologist and Head Department of Anaesthesia and Intensive Care Hospital Tuanku Ja’afar Seremban

Co-Investigators Dr Tai Li Ling Consultant Intensivist Department of Anaesthesia and Intensive Care Hospital Kuala Lumpur

Dr Tan Cheng Cheng Consultant Intensivist Department of Anaesthesia and Intensive Care Hospital Sultanah Aminah Johor Bahru

Dr As-Niza Abdul Shukor Consultant Anaesthesiologist and Head Department of Anaesthesia and Intensive Care Hospital Taiping

Dr Ahmad Shaltut Othman Consultant Intensivist Department of Anaesthesia and Intensive Care Hospital Sultanah Bahiyah Alor Setar

Dr Lim Chew Har Consultant Intensivist Department of Anaesthesia and Intensive Care Hospital Pulau Pinang

Project Manager Sr Lim Siew Kim Department of Anaesthesia and Intensive Care Hospital Kuala Lumpur

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PARTICIPATING HOSPITALS

No. Name of hospital Abbreviation

Sites since 2002

1. Hospital Sultanah Bahiyah Alor Setar AS

2. Hospital Pulau Pinang PP

3. Hospital Raja Permaisuri Bainun Ipoh IPH

4. Hospital Kuala Lumpur KL

5. Hospital Selayang SLG

6. Hospital Tengku Ampuan Rahimah Klang KLG

7. Hospital Tuanku Ja’afar Seremban SBN

8. Hospital Melaka MLK

9. Hospital Sultanah Aminah Johor Bahru JB

10. Hospital Tengku Ampuan Afzan Kuantan KTN

11. Hospital Sultanah Nur Zahirah Kuala Terengganu KT

12. Hospital Raja Perempuan Zainab II Kota Bharu KB

13. Hospital Umum Sarawak Kuching KCH

14. Hospital Queen Elizabeth Kota Kinabalu KK

Sites since 2005

15. Hospital Sultan Abdul Halim Sungai Petani SP

16. Hospital Putrajaya PJY

17. Hospital Pakar Sultanah Fatimah Muar MUR

18. Hospital Teluk Intan TI

19. Hospital Taiping TPG

20. Hospital Seberang Jaya SJ

21. Hospital Kajang KJG

22. Hospital Tuanku Fauziah Kangar KGR

Sites since 2006

23. Subang Jaya Medical Centre SJMC

24. Hospital Sultan Haji Ahmad Shah Temerloh TML

25. Hospital Tuanku Ampuan Najihah Kuala Pilah KP

26. Hospital Sri Manjung SMJ

27. Hospital Batu Pahat BP

28. Hospital Tawau TW

29. Hospital Miri MRI

30. Hospital Kulim KLM

31. Hospital Serdang SDG

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Sites since 2010

32 Hospital Sibu SB

33 Hospital Duchess of Kent Sandakan DKS

34 Hospital Sultan Ismail Johor Bahru SI

35 Hospital Sungai Buloh SBL

36 Hospital Ampang AMP

37 Hospital Wanita dan Kanak-Kanak Sabah LIK

Sites since 2012

38 University Malaya Medical Centre UMMC

39 Langkawi LKW

40 Bukit Mertajam BM

41 Slim River SLR

42 Port Dickson PD

43 Kuala Krai KKR

44 Segamat SGT

45 Tanah Merah TM

46 Kemaman KEM

47 Kuala Lipis KLP

48 Labuan LAB

49 Keningau KEN

50 Bintulu BIN

51 Lahad Datu LD

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CATEGORIES OF ICU Based on the number of ICU admissions in 2014, for the purpose of MRIC 2014 report

Participating sites Number of admissions

Participating sites with > 1000 admissions

1 Hospital Sungai Buloh 2284

2 Hospital Tengku Ampuan Rahimah Klang 2281

3 Hospital Kuala Lumpur 2144

4 Hospital Sultanah Aminah Johor Bharu 1687

5 Hospital Raja Perempuan Zainab II Kota Bharu 1607

6 Hospital Melaka 1432

7 Hospital Selayang 1426

8 Hospital Sultanah Bahiyah Alor Setar 1331

9 Hospital Raja Permaisuri Bainun Ipoh 1217

10 Hospital Taiping 1182

11 Hospital Sultanah Nur Zahirah Kuala Terengganu

1172

12 Hospital Umum Sarawak Kuching 1140

13 Hospital Pulau Pinang 1134

14 Hospital Sultan Ismail Johor Bahru 1131

15 Hospital Tengku Ampuan Afzan Kuantan 1062

Participating sites with 500 - 999 admissions

16 Hospital Queen Elizabeth Kota Kinabalu 987

17 Hospital Sultan Abdul Halim Sungai Petani 953

18 Hospital Duchess of Kent Sandakan 950

19 Hospital Sultan Haji Ahmad Shah Temerloh 837

20 Hospital Serdang 835

21 Hospital Putrajaya 654

22 Hospital Ampang 634

23 Hospital Pakar Sultanah Fatimah Muar 600

24 Hospital Kulim 555

25 Hospital Tuanku Ja’afar Seremban 541

26 Hospital Tuanku Ampuan Najihah Kuala Pilah 512

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Participating sites with < 500 admissions

27 Hospital Tawau 498

28 Hospital Sultanah Nora Ismail Batu Pahat 459

29 Hospital Sri Manjung 432

30 Hospital Sibu 431

31 Hospital Miri 424

32 Hospital Seberang Jaya 409

33 Hospital Teluk Intan 406

34 Hospital Likas 353

35 Hospital Tuanku Fauziah Kangar 341

36 Hospital Kajang 284

37 Hospital Bintulu 283

38 Hospital Port Dickson 265

39 Hospital Kuala Krai 260

40 Hospital Slim River 223

41 Hospital Lahad Datu 217

42 Hospital Labuan 166

43 Hospital Langkawi 165

44 Hospital Tanah Merah 160

45 Hospital Segamat 150

46 Hospital Keningau 144

47 Hospital Bukit Mertajam 141

48 Hospital Kuala Lipis 96

49 Hospital Kemaman 91

Private hospital

50 Subang Jaya Medical Centre 870

University hospital

51 University Malaya Medical Centre 1334

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LIST OF SITE INVESTIGATORS AND SOURCE DATA COLLECTORS

January – December 2014

No Hospital Site investigator Source data collectors

1 Sultanah Bahiyah Alor Setar Dr Ahmad Shaltut Othman Sr Teoh Shook Lian SN Hafisoh Ahmad SN Haslina Khalid SN Noorazimah Salleh SN Faten Ramiza Ahmad Abdullah

2 Pulau Pinang Dr Lim Chew Har SN Siti Hazlina Bidin SN Rosmawati Yusoff SN Emeelia Zuzana Abdul Wahab

3 Raja Permaisuri Bainun Ipoh Dr Foong Kit Weng SN Saadiah Bidin SN Ng Pek Yoong

4 Kuala Lumpur Dr Tai Li Ling SN Salmi Zawati Serif SN Ismee Jusoh

5 Selayang Dr Laila Kamariah Kamalul Baharin

SN Nor Zaila Saad@ Senafi SN Noor Azwati Daud

6 Tengku Ampuan Rahimah Klang

Dr Sheliza Wahab

SN Latifah Omar SN Tai Yoke Ching SN Rosenah Abdul Rahman

7 Tuanku Ja’afar Seremban Dato’ Dr Jenny Tong May Geok

Sr Lim Yek Fong SN Farawahida Ahmad (from Oct 2014) SN Normah Abdul Taib (till Oct 2014)

8 Melaka Dr Nahla Irtiza Ismail Sr Zaliha Emperan SN Norina Abd Kadir

9 Sultanah Aminah Johor Bahru

Dr Tan Cheng Cheng

Sr Marian Sais ak Sipit SN Aishah Abu Bakar AMO Mohd Zakuan Mohd Nor AMO Hairizam Zulkhifli AMO Mohd Adib Jasni AMO Anand Sivasamy

10 Tengku Ampuan Afzan Kuantan

Dr Muhammad Zihni Abdullah

Sr Gan Soo Heng SN Salina Sulaiman SN Amimah Abd Hamid SN Nur Azura Hamzah (till Oct 2014)

11 Sultanah Nur Zahirah Kuala Terengganu

Dr Mohd Ridhwan Mohd Nor

SN Zauwiah Idris SN Aslinawati Chik

12 Raja Perempuan Zainab II Kota Bharu

Dr Wan Nasrudin Wan Ismail

Sr Azilah Ishak SN Azizum Ismail SN Suzana Yusof

13 Umum Sarawak Kuching Dr.Jamaidah Jamorek SN Noreafa Daim (till April 2014) SN Sabia Lew SN Rosnica Jiton SN Sharon Ivy Gombek

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14 Queen Elizabeth Kota Kinabalu

Dr Khoo Tien Meng SN Conny Chong Chiew Fah SN Aslinda Ahmad (till Oct 2014) SN Saihin Maun SN Suzie Tinus SN Winnie Yasin

15 Sultan Abdul Halim Sungai Petani

Dr Rosman Noor Ali SN Rafizah Md Zuki SN Hamiza Mohd Noor SN Zainun Awang

16 Putrajaya Dr Fauziah Yusoff Sr Latifah Mohd Korib SN Maznah Muhamad

17 Pakar Sultanah Fatimah Muar

Dr Suzaliatun Kasbolah SN Roslina Othman SN Mazlidah Osman SN Nurazlin Jawad SN Fazal Naim Ramli

18 Teluk Intan Dr Noor Azira Haron

SN Azliza Zakaria SN Rohayu Dalila Yusof

19 Taiping Dr As-Niza Abdul Shukor SN Salihah Ahmad SN Che Zakiah Othman SN Rozieyana Mohd Razali

20 Seberang Jaya Dr Leong Chin Tho SN Siti Noormi binti Ahmad SN Mira Nabila binti Ramlan

21 Kajang Dr Nursuhaila binti Mohd Amin

SN Normaizana Ismail SN Rosnani binti Ab.Latip SN Emiza binti Abdullah Zahid

22 Tuanku Fauziah Kangar Dr Azilah Desa

Sr Chua Pek Hong (till Aug 2014) Sr Che Salma binti Abdul Rahman SN Zarina Mat Bistaman SN Norazlisyan Ramli SN Norshaheera Nalini

23 Subang Jaya Medical Center Dr Wong Ket Hiung Ms Navjeet Kaur SN Normazimah Mohamad Nazar

24 Sultan Haji Ahmad Shah Temerloh

Dr Rahimah Haron Sr Rakiah Mohd Noor SN Norliza Ismail SN Rohayu Yusof SN Joliena Jaafar SN Aida Azlina Ali

25 Tuanku Ampuan Najihah Kuala Pilah

Dr Zalifah Nordin Sr Lee New (till Aug 2014) SN Norhafidah Ismail SN Khadijah MD Taher

26 Sri Manjung Dr Khairudin Zainal Abidin Sr Rohani Ali Sr Hartini Abd Rahman SN Salbiah Abdul Rashid SN Norfaizal Abdul Majid

27 Batu Pahat Dr Nasrudin Bunasir SN Rosmawati Saimin SN Norhaezah Jani

28 Tawau Dr Sein Win SN Lilybeth Feliciano Ferez SN Sarwah Isa SN Sharifah Maznah Habib Muhammad

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29 Miri Dr Lim Hong Jin (till Aug 2014) Dr Norhuzaimah Binti Julai Abdul Julaihi

SN Noriah Ilai SN Zuriha Achim

30 Kulim Dr Chua Kok Boon

Sr Mahani binti Hassan SN Mohana Omar SN Bahayah Mohamed Bakari SN Che Asmah Haji Md Isa

31 Serdang Dr Nazarinna Muhamad Sr Norain Saad (till Mar 2014) Sr Siti Ainah Binti Buang SN Sarina Jamhari

32 Sibu Dr Anita Alias SN Wong Chen Chen SN Yong Suk Moi

33 Duchess of Kent Sandakan Dr Rusnah Abd Rahman

Sr Noorasmah Hassim SN Norahimah Dulraman SN Sofiah Yampi

34 Sultan Ismail Johor Bahru Dr Mohd Zaini Laman Sr Azleena Mohd Yusop SN Huzaimah Jahir (till June 2014) SN Norwati Jamiran SN Norelessa Abd Aziz

35 Sungai Buloh Dr Shanti Ratnam Sr Sri Jayanthi Gobalan Sr Noorhaidah Baharuddin SN Siti Salwa binti Mohd Latif

36 Ampang Dr Rusnah Ab.Latif Sr Normazlin Md Derus SN Amiza Dyana Abu Amin SN Asilah Fatin

37 Wanita dan Kanak-Kanak Sabah

Dr Lorrain Lim

SN Siti Rajiah bt Muslimin SN Dayang Noreenz Mohd Yusoh SN Yusnita bt Yunus

38 University Malaya Medical Centre

Dr Vineya Rai Sr Azizah Md Lajis SN Nur Aina Muhamad

39 Langkawi Dr Suriana binti Mohd Abu Bakar

Sr Hamiza Harun

40 Bukit Mertajam Dr Nur Sabrina Mohd Sabry (till Sept 2014) Dr Tan Mei Xuan

Sr Thanaletchimi Packirisamy SN Faizah Abdul

41 Slim River Dr Tin Tin Myint

Sr Khairol Nazimah Musa SN Suliati Baghdadi

42 Port Dickson Dr Hema Malini Manogharan

Sr Hapisah Mat SN Muhazni Mohammad

43 Kuala Krai Dr Norhafidza Ghazali

Sr Norlela Ismail SN Salma binti Ismail

44 Segamat Dr Wirza Feldi Bin Sawir Sr Hasneyza Bakar Sr Khatijah binti Yusof

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45 Tanah Merah Dr Mohd Azmi Mamat Sr Norain binti Saad SN Fadilah bt Mohd Nor

46 Kemaman Dr Ahmad Nizam Ismail Sr Rosmazariawati Zahari

47 Kuala Lipis Dr Wan Satifah Wan Ngah (till Feb 2014) Dr Sharihanim bt Hussain

Sr W. Norlizer W.Muda (till Oct 2014) SN Nik Arienti Nik Man Sr Potchaine a/p Ek Kam

48 Labuan Dr Betty Shee Sr Roslin Akiu SR Loinsah Sibin

49 Keningau Dr Fazilawati bt Zakaria (till August 2014) Dr Maswiana Abdul Majid

Sr Haineh Amin Sr Icha Chim

50 Bintulu Dr Siti Intan Zurhaida bt Mohd Zainol Abidin (till Sept 2014) Dr Hairatun Ida binti Md Hamzah

Sr Jennifer Anak Sahim Sr Raimah Sebli SN Ann Lampung SN Yuhana Dalang

51 Lahad Datu Dr Norazura Ahmad@Said Sr Juraini bt Mohd Jaffar SN Noorlaila btDurahman

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ABBREVIATIONS

Adm. Admission

AKI Acute kidney injury

ALI Acute lung injury

AMO Assistant medical officer

AOR At own risk

APACHE II Acute Physiologic and Chronic Health Evaluation (Version II)

ARDS Acute respiratory distress syndrome

BOR Bed occupancy rate

CRBSI Catheter related bloodstream infection

CRRT Continuous renal replacement therapy

CVC Central venous catheter

CVC-BSI Central venous catheter-related bloodstream infection

ED Emergency department

ENT Otorhinolaryngology

HD Haemodialysis

HDU High dependency unit

Hosp Hospital

Hrs Hours

ICU Intensive care unit

MOH Ministry of Health

MRIC Malaysian Registry of Intensive Care

MRO Multi-drug resistant organism

MRSA Methicillin-resistant Staphylococcus aureus

MSSA Methicillin-sensitive Staphylococcus aureus

NAICU National Audit on Adult Intensive Care Units

NIV Non-invasive ventilation

NHSN National Healthcare Safety Network

No./n Number

O&G Obstetrics & Gynaecology

PaCO2 Partial pressure of arterial carbon dioxide

PaO2 Partial pressure of arterial oxygen

Refer. Referred

SAPS II Simplified Acute Physiologic Scoring System (Version II)

SD Standard deviation

SIRS Systemic inflammatory response syndrome

SMR Standardised mortality ratio

SN Staff nurse

SOFA Sequential Organ Failure Assessment

Sr Sister

SPSS Statistical Package for Social Sciences

VAP Ventilator-associated pneumonia

VCB Ventilator care bundle

Yrs Years

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LIST OF TABLES

Page Table 1 No. of ICU beds and ICU bed occupancy rate, by MOH hospitals 2010 - 2014………………. 23 Table 2 ICU admissions, by individual hospital 2010 – 2014…………………………………………….. 25 Table 3 Reporting rates, by individual hospital 2010 – 2014……………………………………………... 29 Table 4 Intensive care referrals and refusal of admission, by individual hospital 2010 – 2014……….. 31 Table 5 Gender 2010 – 2014………………………………………………………………………………….. 34 Table 6 Mean age 2010 – 2014……………………………………………………………………………….. 34 Table 7 Ethnic groups 2014…………………………………………………………………………………... 35 Table 8 Length of ICU stay, by individual hospital 2010 – 2014…………………………………………. 36 Table 9 Length of hospital stay, by individual hospital 2010 – 2014…………………………………….. 38 Table 10 Referring units, by category of ICU 2014 …………………………………………………………. 40 Table 11 Category of patients, by category of ICU 2014…………………………………………………… 41 Table 12 Category of patients in MOH hospitals 2010 – 2014……………………………………………... 42 Table 13 Location before ICU admission, by category of ICU 2014………………………………………. 43 Table 14 Location before ICU admission in MOH hospitals 2010 – 2014………………………………… 44 Table 15 Main organ failure on ICU admission, by category of ICU 2014………………………………. 45 Table 16 Number of organ failure(s) on ICU admission, by category of ICU 2014……………………... 46 Table 17 Ten most common diagnoses leading to ICU admission 2014………………………………….. 47 Table 18 Ten most common diagnoses leading to ICU admission using APACHE II diagnostic

category 2014………………………………………………………………………………………....

49 Table 19 Severe sepsis, ARDS and AKI within 24 hours of ICU admission 2014……………………….. 50 Table 20 Severe sepsis, ARDS and AKI within 24 hours of ICU admission, by individual hospital

2012 - 2014……………………………………………………………………………………………

51 Table 21 SAPS II score, by individual hospital 2010 – 2014………………………………………………... 53 Table 22 SOFA score, by individual hospital 2010 – 2014………………………………………………….. 54 Table 23 Invasive ventilation, non-invasive ventilation and reintubation, by category of ICU 2014…. 57 Table 24 Duration of invasive ventilation, by individual hospital 2010 – 2014………………………….. 60 Table 25 Renal replacement therapy and modalities of therapy, by category of ICU 2014…………….. 61 Table 26 Tracheostomy, by category of ICU 2014…………………………………………………………... 63 Table 27 Tracheotomy, by individual hospital 2014………………………………………………………... 64 Table 28 Total number of tracheostomies and % percutaneous trachestomies, by individual hospital

2010 -2014………………………………………………......................................................................

65 Table 29 Withdrawal /withholding of therapy, by individual hospital 2010 – 2014…………………… 67 Table 30 Incidence of Ventilator-associated pneumonia, by individual hospital 2009 – 2014……………… 70 Table 31 Onset of VAP from initiation of invasive ventilation, by individual hospital 2010 – 2014…… 71 Table 32 Bacteriological cultures in VAP, by category of ICU 2014………………………………………. 75 Table 33 Bacteriological cultures in VAP 2008 – 2014……………………………………………………… 76 Table 34 Extra length of mechanical ventilation, ICU stay and crude in-hospital mortality in patients

with VAP 2013-2014…………………………………………………………………………………………

77 Table 35 Unplanned extubation, by individual hospital 2010 – 2014……………………………………… 78 Table 36 Pressure ulcer, by individual hospital 2010 - 2014 ………………………………………………. 81 Table 37 ICU outcome, by category of ICU 2014…………………………………………………………………… 85 Table 38 Hospital outcome, by category of ICU 2014 ……………………………………………………………… 85 Table 39 Crude in-ICU and in-hospital mortality rates, by individual hospital 2010 – 2014…………... 86 Table 40 Ten most common diagnoses leading to ICU admission in MOH hospitals and observed

in-hospital mortality 2010 - 2014…………………………………………………………………………….

89 Table 41 Severe sepsis, ARDS and AKI within 24hrs of ICU admission and observed in-hospital

mortality 2012– 2014…………………………………………………………………………………….

89 Table 42 Standardised mortality ratio, by individual hospital 2010 - 2014………………………………… 90 Table 43 Ventilator care bundle compliance, by individual hospital 2010 – 2014……………………………. 93 Table 44 Catheter utilisation ratio, central venous catheter care bundle compliance and incidence

of central venous catheter- related bloodstream infection 2013 - 2014………………………….

95 Table 45 Bacteriological cultures in CVC-BSI 2013-2014……………………………………………………… 98 Table 46 General comparison for dengue infection MOH ICUs 2010 - 2014……………………………………… 104 Table 47 Dengue infection by individual hospital and crude all cause in-hospital mortality 2010 -2014..…….. 105

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LIST OF FIGURES

Page

Figure 1 ICU admissions 2003 – 2014…………………………………………………….……………. 26

Figure 2 ICU admissions, by participating centres 2014 ……………………………………………. 27

Figure 3 Age groups 2014 ………………………………………………………………....................... 34

Figure 4 Ethnic groups 2014 ……………………………………………………………....................... 35

Figure 5 Referring units, by category of ICU 2014 …………………………………………………………… 41

Figure 6 Category of patients, by category of ICU 2014 ……………………………………………. 42

Figure 7 Category of patients, MOH hospitals 2004 – 2014………………………………………… 42

Figure 8 Location before ICU admission, by category of ICU 2014 ……………………………….. 43

Figure 9 Location before ICU admission in MOH hospitals 2004 – 2014…………………………. 44

Figure 10 Main organ failure on ICU admission, by category of ICU 2014………………………… 45

Figure 11 Number of organ failure(s) on ICU admission, by category of ICU 2014 ……………… 46

Figure 12 Ten most common diagnoses leading to ICU admission in MOH hospitals 2014…….. 48

Figure 13 Invasive ventilation, by category of ICU 2014……………………………………….......... 57

Figure 14 Non-invasive ventilation, by category of ICU 2014………………………………………. 58

Figure 15 Non-invasive ventilation, MOH hospitals 2005 – 2014…………………………………… 58

Figure 16 Reintubation by category of ICU 2014……………………………………………………… 59

Figure 17 Reintubation, MOH hospitals 2004 – 2014…………………………………………………. 59

Figure 18 Renal replacement therapy by category of ICU 2014……………………………………... 62

Figure 19 Modalities of renal replacement therapy, by category of ICU 2014 ……………………. 62

Figure 20 Techniques of tracheostomy, by category of ICU 2014 …………………………….......... 63

Figure 21 Ventilator associated pneumonia 2004 - 2014 …………………………………………….. 72

Figure 22 Ventilator associated pneumonia, by individual hospital 2014………………………….. 73

Figure 23 Bacteriological cultures in VAP, by category of ICU 2014 ………………………………. 75

Figure 24 Common bacteriological cultures in VAP 2008 – 2014……………………………………. 76

Figure 25 Unplanned extubation, by individual hospital 2014……………………………………… 80

Figure 26 Pressure ulcers, by individual hospital 2014………………………………………………. 83

Figure 27 Crude in-ICU and in-hospital mortality rates, by individual hospital 2014……………. 88

Figure 28 Ventilator care bundle compliance and VAP 2007 – 2014………………………………………. 94

Figure 29 Catheter utilisation ratio, central venous catheter care bundle compliance and incidence of central venous catheter-related bloodstream infection by hospital 2014….

97

Figure 30 Compliance to Early Mobility in ICU protocol by hospital 2014………………………… 101

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INTRODUCTION The National Audit on Adult Intensive Care Units (NAICU) was established in 2002 as a

quality improvement initiative to systematically review the intensive care practices in

Malaysia and where possible, to introduce remedial measures to improve outcome. To date,

this audit has published eleven yearly reports and introduced several quality measures such

as ventilator care bundle, central venous catheter care bundle, early mobility in ICU and the

SSKIN bundle.

In 2009, the NAICU was renamed the Malaysian Registry of Intensive Care (MRIC). This

report is the seventh for MRIC, but twelfth in the series.

The objectives of this registry are to:

1. Establish a database of patients admitted to the adult ICUs

2. Review the clinical practices of intensive care

3. Determine clinical outcome

4. Determine the resources and delivery of intensive care service

5. Evaluate the impact of quality improvement measures on patient care

6. Provide comparisons of performance of participating centres against national and

international standards

7. Conduct healthcare research related to intensive care

In 2002, 14 state hospitals were first recruited into the audit. The number of centres increased

to 22 in 2005. In 2006, 9 more centres were added to the list of participating sites, including

one private hospital in Selangor. In 2010, 6 more centres were added to the list of 31

participating hospitals. In 2012, the total number of participating centres expanded to 51

with 49 MOH hospitals, 1 private hospital and 1 university hospital.

This report describes the intensive care practices and outcomes in 49 ICUs in MOH, 1 ICU in

a private hospital and 1 ICU in a university hospital.

Data Collection and Verification Data were collected prospectively by trained nurses (source data providers) and specialists

(site investigators) based on a written protocol. Data was initially collected on a standard e-

case report form for each patient. Since 1st January 2010, data were entered directly in a

central depository via a web-based programme by individual centres.

All participating centres were to ensure “accuracy and completeness” of their individual

databases.

Merged data were ‘cleaned’ and verified before being analysed using SPSS version 20.0.0.

21

This report is based on all admissions into the 51 participating ICUs from 1st January to 31st

December 2014. The total number of admissions in 2014 was 41,370 out of which 2368 (5.7%)

were readmissions. For patients with multiple ICU admissions, only the first admission was

included in the analysis.

Due to missing and inconsistent data, the sum total of some variables shown in the tables

may not add up to the actual number of admissions.

Data Limitations

Limitations to the registry data were mainly related to data collection and data entry. Some

of the participating ICUs experienced rapid turnover of their site investigators and source

data providers resulting in under-reporting and data inconsistencies. Data from several

centres with low reporting rates were excluded from some of the analysis of the variables.

Format of Report The format of this report follows the patient’s journey in four sections: demographics,

interventions, complications and outcomes. Information is reported on a total of 38,904 ICU

admissions.

In this report, information was provided for individual centres. Wherever appropriate,

comparisons were made between three categories of hospitals based on the number of ICU

admissions. MOH hospitals were divided into three categories: centres with 1000 admissions

and more, centres with 500 to 999 admissions and those with less than 500 admissions.

Where relevant, trends of certain variables over the years were reported.

This report also includes ICU admissions for dengue infection, central venous care bundle

compliance, central venous catheter-related bloodstream infections and early mobility in

ICU compliance in MOH participating centres.

22

SECTION A:

GENERAL INFORMATION

23

Table 1 : No. of ICU beds and bed occupancy rate, by MOH hospitals, 2010–2014 Hospital

Number of functional

ICU beds (as of 31-12-2014)

Median ICU bed occupancy rate %

2010 2011 2012 2013 2014

AS 24 83.2 87.0 96.7 93.3 88.8

PP 22 61.5 89.9 88.7 90.9 90.5

IPH 26 104.0 107.0 106.0 104.0 109.0

KL 30 109.3 107.5 111.7 110.6 114.1

SLG 24 97.7 111.4 99.8 101.8 92.7

KLG 32 91.9 87.8 108.3 105.9 112.9

SBN 8 114.0 118.4 114.6 108.3 111.7

MLK 24 88.1 106.0 107.9 97.5 90.7

JB 29 108.7 106.2 105.6 109.4 109.0

KTN 18 103.0 105.2 106.4 106.5 110.3

KT 21 93.9 102.0 103.6 104.6 94.2

KB 20 88.5 80.8 80.0 96.2 109.2

KCH 16 104.9 116.6 125.9 101.0 107.6

KK 21 100.1 101.7 93.4 95.9 90.9

SP 16 80.9 84.6 84.9 92.5 82.7

PJY 11 89.5 78.2 75.2 71.2 84.7

MUR 8 89.6 82.4 97.5 97.5 94.2

TI 4 91.0 101.3 123.8 105.2 114.0

TPG 20 98.4 103.2 92.7 84.7 81.4

SJ 10 90.7 89.6 99.1 80.2 81.3

KJG 6 75.6 78.9 77.2 77.1 84.2

KGR 5 70.2 63.3 77.3 78.1 80.8

TML 18 110.5 104.0 113.0 127.0 88.8

KP 8 56.2 68.5 61.8 72.4 91.7

SMJ 8 79.0 82.4 92.7 85.5 92.4

BP 7 71.4 69.0 87.0 79.6 74.8

TW 10 82.5 60.6 80.7 70.0 78.2

MRI 8 79.7 72.7 76.1 79.6 101.3

KLM 7 99.2 98.9 100.5 95.4 100.2

SDG 13 87.4 88.2 50.4 84.4 85.7

SB 13 102.6 99.2 60 120.5 144.0

DKS 16 116.2 87.9 87.9 99.1 82.2

SI 21 79.2 87.3 86.2 90.2 85.1

SBL 38 118.2 108.1 94.6 94.0 115.7

AMP 12 89.0 85.5 45.7 82.9 74.4

LIK 9 62.0 76.7 76.9 106.0 103.4

LKW 4 - - 67.0 67.4 59.1

BM 6 - - 65.6 106.8 100.9

24

SLR 5 - - 76.0 71.0 79.3

PD 4 - - 85.5 65.6 86.0

KKR 5 - - 69.8 85.2 87.1

SGT 4 - - 58.1 89.7 75.0

TM 2 - - 68.7 74.0 113.2

KEM 2 - - 59.6 50.9 -

KLP 3 - - 21.8 53.0 54.2

LAB 5 - - 30.7 41.2 45.5

KEN 4 - - 90.4 78.0 80.3

BIN 6 - - 88.3 63.2 59.7

LD 4 - - 104.2 101.2 103.1

Total 637 - - - -

Median - 90.2 88.6 86.2 90.2 90.5

The total number of ICU beds in the 49 MOH hospitals as of 31st December 2014 was 637 with a median bed occupancy rate (BOR) of 90.5%. There was a 6.1% increase (37 beds) in the number of ICU beds from the previous year. There was a wide variation in the BOR across the centers. Four hospitals, KL, SBN, JB and KTN continuously had their bed occupancy rate more than 100% for the past 5 years while LAB had a consistently low BOR of approximately 40%. Bed occupancy is used as a measure to indicate the activity of a unit in terms of its maximum capacity. There are several methods of calculating bed occupancy and the impact of these methodological differences will tend to be greatest in specialised areas such as intensive care units, where the duration of admission is generally short but highly variable, and throughput is high. If it is measured in whole numbers of days, intensive care units can show an occupancy of greater than 100%, as more than one patient may use a particular bed on a given day. It is believed that some MOH ICUs still use the “midnight count” method to calculate BOR and hence BOR maybe lower than if the throughput method was used.

25

Table 2 : ICU admissions, by individual hospital 2010 – 2014 Hospital

2010 2011 2012 2013 2014

n (%) n (%) n (%) n(%) n (%)

AS 1094 (4.1) 1212 (4.1) 1201 (3.5) 1347 (3.6) 1331 (3.4)

PP 911 (3.4) 1198 (4.0) 1287 (3.8) 1121 (3.0) 1134 (2.9)

IPH 1143 (4.2) 1140 (3.8) 926 (2.7) 1203 (3.2) 1217 (3.1)

KL 1947 (7.2) 1842 (6.2) 1971 (5.8) 1905 (5.1) 2144 (5.5)

SLG 1053 (3.9) 1141 (3.8) 1289 (3.8) 1507 (4.0) 1426 (3.7)

KLG 1215 (4.5) 1608 (5.4) 2136 (6.3) 2065 (5.5) 2281 (5.9)

SBN 542 (2.0) 554 (1.9) 537 (1.6) 471 (1.3) 541 (1.4)

MLK 1636 (6.1) 1593 (5.3) 1694 (5.0) 1673 (4.5) 1432 (3.7)

JB 1443 (5.3) 1685 (5.7) 1752 (5.2) 1931 (5.2) 1687 (4.3)

KTN 744 (2.8) 612 (2.1) 641 (1.9) 837 92.2) 1062 (2.7)

KT 1087 (4.0) 1207 (4.1) 1363 (4.0) 1180 (3.2) 1172 (3.0)

KB 826 (3.1) 1125 (3.8) 1286 (3.8) 1337 (3.6) 1607 (4.1)

KCH 512 (1.9) 643 (2.2) 854 (2.5) 950 (2.5) 1140 (2.9)

KK 808 (3.0) 843 (2.8) 954 (2.8) 1022 (2.7) 987 (2.5)

SP 207 (0.8) 270 (0.9) 159 (0.5) 583 (1.6) 953 (2.4)

PJY 523 (1.9) 537 (1.8) 574 (1.7) 606 (1.6) 654 (1.7)

MUR 759 (2.8) 473 (1.6) 636 (1.9) 675 (1.8) 600 (1.5)

TI 276 (1.0) 308 (1.0) 384 (1.1) 401 (1.1) 406 (1.0)

TPG 834 (3.1) 860 (2.9) 1203 (3.5) 1348 (3.6) 1182 (3.0)

SJ 590 (2.2) 579 (1.9) 644 (1.9) 413 (1.1) 409 (1.1)

KJG 323 (1.2) 341 (1.1) 371 (1.1) 321 (0.9) 284 (0.7)

KGR 294 (1.1) 298 (1.0) 350 (1.1) 322 (0.9) 341 (0.9)

SJMC 1578 (5.8) 2018 (6.8) 1467 (4.3) 1335 (3.6) 870 (2.2)

TML 624 (2.3) 543 (1.8) 436 (1.3) 599 (1.6) 837 (2.2)

KP 234 (0.9) 359 (1.2) 334 (1.0) 394 (1.1) 512 (1.3)

SMJ 314 (1.2) 380 (1.3) 403 (1.2) 376 (1.0) 432 (1.1)

BP 409 (1.5) 454 (1.5) 415 (1.2) 459 (1.2) 459 (1.2)

TW 238 (0.9) 274 (0.9) 433 (1.3) 449 (1.2) 498 (1.3)

MRI 302 (1.1) 385 (1.3) 478 (1.4) 481 (1.3) 428 (1.1)

KLM 474 (1.8) 498 (1.7) 601 (1.8) 561 (1.5) 555 (1.4)

SDG 824 (3.1) 883 (3.0) 875 (2.6) 851 (2.3) 835 (2.1)

SB 471 (1.7) 569 (1.9) 490 (1.4) 506 (1.4) 431 (1.1)

DKS 246 (0.9) 526 (1.8) 526 (1.6) 964 (2.6) 950 (2.4)

SI 568 (2.1) 647 (2.2) 806 (2.4) 970 (2.6) 1131 (2.9)

SBL 1234 (4.6) 1260 (4.2) 1583 (4.7) 1922 (5.1) 2284 (5.9)

AMP 534 (2.0) 553 (1.9) 572 (1.7) 566 (1.5) 634 (1.6)

LIK 160 (0.6) 376 (1.3) 270 (0.8) 517 (1.4) 353 (0.9)

UMMC - - 474 (1.4) 883 (2.4) 1344 (3.5)

26

LKW - - 157 (0.5) 180 (0.5) 165 (0.4)

BM - - 38 (0.1) 158 (0.4) 141 (0.4)

SLR - - 154 (0.5) 225 (0.6) 223 (0.6)

PD - - 204 (0.6) 245 (0.7) 265 (0.7)

KKR - - 149 (0.4) 240 (0.6) 260 (0.7)

SGT - - 127 (0.4) 159 (0.4) 150 (0.4)

TM - - 17 (0.1) 127 (0.3) 160 (0.4)

KEM - - 94 (0.3) 105 (0.3) 91 (0.2)

KLP - - 7 (0.0) 116 (0.3) 96 (0.2)

LAB - - 107 (0.3) 165 (0.4) 166 (0.4)

KEN - - 82 (0.2) 161 (0.4) 144 (0.4)

BIN - - 213 (0.6) 260 (0.7) 283 (0.7)

LD - - 168 (0.5) 244 (0.7) 217 (0.6)

Total 26977 (100) 29794 (100) 33892 (100) 37436 (100) 38904 (100)

Figure 1 : ICU admissions, 2003 – 2014

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

2003' 2004' 2005' 2006' 2007' 2008' 2009' 2010' 2011' 2012' 2013' 2014'

Cohort of first 14 ICUs All participating ICUs

27

Figure 2 : ICU admissions, by participating centres 2014

28

The number of admissions had increased over the years in the MOH hospitals. There was an increase of 44% over the past five years from 2010 to 2014. This was attributed to the increase in the number of participating centres, increase in the number of ICU beds in the existing centres and an increase in ICU admissions. For the initial cohort of 14 hospitals recruited in 2002, the number of admissions increased from 14,961 to 19,161 (an increase of 28%) over the last 5 years. There was an increase of 25% in the number of ICU beds from 251 to 315 over the same period of time for the same cohort. Readmission within 48 hours is commonly used as an indicator of intensive care patient management, as it might reflect premature ICU discharge or substandard ward care. Although readmission is associated with high mortality, it is unclear whether it reflects substandard practices within a hospital. Low readmission rate may be due to inability to readmit patients due to unavailability of ICU beds. The readmission rate within the first 48 hours of ICU discharge for the 49 MOH centres was 1.5% in 2014. This rate has varied from 1.3% to 2.1% over the past five years. In a retrospective study done from 2001 to 2007, in 106 ICUs in United States of America, approximately 2% of ICU patients discharged to the ward were readmitted within 48 hours [1]. The Australian Council on Healthcare Standards reported a readmission rate of 1.68% from 2003 to 2010 [2].

29

Table 3 : Reporting rates, by individual hospital 2010 – 2014 Hospital 2010

% 2011

% 2012

% 2013

% 2014

% AS 92.2 98.2 93.1 99.6 91.5

PP 87.4 90.1 96.2 92.2 94.1

IPH 96.3 99.2 97.5 95.9 91.0

KL 94.8 98.7 98.5 95.0 94.7

SLG 94.8 95.0 97.6 95.3 92.8

KLG 91.1 86.0 97.3 97.7 95.9

SBN 96.4 99.5 99.3 97.3 96.8

MLK 94.8 99.5 98.8 95.2 94.8

JB 97.4 99.8 97.2 95.7 95.4

KTN 94.8 99.0 97.2 124.4* 88.4

KT 96.1 99.8 99.1 95.0 90.4

KB 95.7 94.4 98.7 83.0 100.7*

KCH 87.5 94.3 95.3 89.6 93.2

KK 89.4 95.4 94.9 95.2 95.3

SP 38.5 53.1 30.8 106.0* 92.7

PJY 96.5 99.1 98.0 92.9 86.6

MUR 63.0 97.4 94.6 98.0 92.0

TI 92.0 98.4 91.2 90.3 94.0

TPG 95.5 94.0 99.3 95.5 94.3

SJ 95.2 98.5 98.3 85.7 73.4

KJG 81.4 95.5 99.7 75.2 57.7

KGR 97.0 98.1 98.6 94.2 95.5

TML 87.4 81.4 62.6 68.3 91.0

KP 98.3 100.0 66.4 51.0 94.6

SMJ 95.4 100.0 99.5 97.9 94.9

BP 95.1 98.5 97.9 106.3* 97.2

TW 78.3 91.7 98.6 95.5 94.0

MRI 94.1 88.5 99.2 97.6 78.0

KLM 95.2 98.9 98.5 94.1 92.2

SDG 66.7 94.9 90.5 108.4* 97.0

SB 74.8 73.1 70.0 46.7 25.7

DKS 54.8 99.6 95.5 92.7 90.3

SI 92.4 86.3 94.6 97.3 95.0

SBL 92.5 100.0 90.7 82.0 89.6

AMP 95.5 85.2 100.0 97.1 119.6*

LIK 27.2 60.9 57.4 80.7 59.9

LKW - - 69.8 87.4 82.5

BM - - 11.3 39.4 34.7

SLR - - 42.5 67.6 67.8

30

PD - - 84.0 93.2 92.7

KKR - - 87.1 94.9 102.4*

SGT - - 41.2 50.5 20.1

TM - - 22.4 104.1* 32.4

KEM - - 75.2 82.0 74.6

KLP - - 36.8 87.9 43.2

LAB - - 96.4 91.2 89.2

KEN - - 16.4 59.2 56.5

BIN - - 75.5 80.5 84.0

LD - - 67.2 92.4 83.5

* These hospitals had reporting rates more than 100%.

The reporting rate is calculated by comparing the number of ICU admissions reported to the MRIC and to the national census, collected by the Head of Anaesthesia service. The total number reported to the MRIC should be equal or slightly less than that of the national census, as patients who were still in hospital on 31st January 2015 were excluded in the analysis. The following hospitals have consistently contributed high reporting rates of over 90% over the last 5 years: AS, IPH, KL, SLG, SBN, MLK, JB, KT, TI, TPG, KGR, SMJ, BP and KLM. On the other hand, the following hospitals have been having low reporting rates of less than

50% over the last 5 years: SB, LIK, BM, SLR, SGT and KEN.

31

Table 4 : Intensive care referrals and refusal of admission, by individual hospital 2010 – 2014

Hosp

2010 2011 2012 2013 2014

No. refer.

% denied adm.

No. refer.

% denied adm.

No. refer.

% denied adm.

No. refer.

% denied adm.

No. refer.

% denied adm.

AS * * * * * * * * * *

PP 1292 83.3 942 70.2 1329 67.8 1365 73.6 1145 66.1

IPH 1275 69.3 1525 66.7 1834 63.4 1639 70.2 1852 62.2

KL 2218 34.6 1971 32.8 2364 30.4 2515 30.1 3393 30.0

SLG 151 40.4 448 27.2 1173 24.2 1537 35.3 1449 28.2

KLG 2155 56.7 2264 33.1 2458 21.2 2576 23.1 31.40 21.2

SBN 1862 59.3 2125 60.8 1929 56.0 1640 51.6 853 49.1

MLK 1035 70.3 919 55.2 993 61.2 1285 73.9 2451 43.0

JB 2065 50.4 2069 39.8 2205 28.8 2634 33.7 2495 40.9

KTN 1092 29.1 791 42.4 455 39.6 608 40.0 241 29.5

KT 264 20.1 150 18.0 544 26.3 183 27.9 443 19.6

KB 1399 63.3 1431 50.1 1417 41.5 1884 46.9 2817 46.8

KCH 326 61.4 477 51.4 1132 57.8 1271 53.1 1474 52.7

KK 992 13.2 1340 16.0 1282 13.0 1619 21.7 1364 17.9

SP * * * * 254 44.1 562 46.1 74 21.6

PJY * * * * 36 5.6 486 0.6 * *

MUR 619 15.8 685 31.4 903 34.3 1223 31.5 1368 28.7

TI 186 21.0 54 40.7 170 42.9 156 49.1 440 49.3

TPG 902 2.0 958 0.5 1498 10.4 2004 12.4 1360 6.5

SJ 758 23.5 625 31.2 592 34.1 813 41.7 657 28.9

KJG 170 5.3 67 19.4 * * 488 22.1 145 37.9

KGR 230 21.7 201 20.4 405 12.8 390 16.7 397 15.1

TML 800 35.3 921 35.6 875 38.5 836 37.6 834 38.3

KP 372 33.3 412 7.3 412 9.7 587 21.8 684 14.0

SMJ 203 16.3 191 13.1 145 13.8 122 12.3 232 2.6

BP 382 8.6 454 2.6 372 2.2 458 3.7 443 1.1

TW 250 0.0 297 * 505 3.2 591 5.4 844 19.1

MRI 141 16.3 81 18.5 132 4.6 335 22.4 61 13.1

KLM 411 2.9 509 2.9 710 5.2 699 10.7 730 6.6

SDG 581 21.5 712 14.2 506 22.9 1221 10.2 1525 12.0

SB * * * * * * 565 22.5 506 22.7

DKS 130 38.5 10 50.0 214 33.6 81 26.0 246 20.3

SI 478 35.6 635 34.8 547 21.4 734 31.7 484 28.5

SBL 119 40.3 * * 689 17.4 636 14.8 1607 9.2

AMP * * 149 39.6 716 26.7 1333 29.5 1419 21.9

LIK * * * * * * * * * *

UMMC

- - - - 657 57.5 955 41.8 55 34.6

LKW - - - - * * 171 0.6 *

*

32

BM - - - - * * * * * *

SLR - - - - 55 10.9 166 7.2 277 2.5

PD - - - - 216 7.4 249 1.6 288 0.7

KKR - - - - 49 24.5 105 27.6 263 36.5

SGT - - - - * * * * * *

TM - - - - * * 95 3.2 148 10.1

KEM - - - - 60 1.7 119 12.6 122 11.5

KLP - - - - * * 100 3.0 99 6.1

LAB - - - - * * * * * *

KEN - - - - 46 4.4 * * * *

BIN - - - - * * * * * *

LD - - - - * * * * 67 43.3

Total 22861 36.5 25321 34.2 31341 32.0 37962 29.4 39586 29.8

* Missing data

The reason for ICU refusal for the purpose of this registry was limited to the unavailability of ICU beds. In 2014, 30% of patients were denied ICU admission. Over the past five years, the percentage of patients denied ICU admission has reduced steadily due to the overall increase in the number of ICU beds in most MOH hospitals. In an observational prospective study, the ICU refusal rates varied greatly across ICUs in 11 hospitals in France ranging from 7.1 to 63.1%, with reasons for refusal as being too well to benefit, too sick to benefit and unavailability of ICU beds [3].

33

SECTION B:

PATIENT CHARACTERISTICS

34

Table 5 : Gender 2010-2014

Gender

2010 n (%)

2011 n (%)

2012 n (%)

2013 n (%)

2014 n (%)

Male 16040 (59.6) 17788 (59.7) 20295 (60.0) 22331 (59.7) 22926 (59.0)

Female 10875 (40.4) 11968 (40.2) 13554 (40.0) 15048 (40.3) 15895 (41.0)

The ratio of male to female patients (3:2) has remained fairly constant over the past five years.

Table 6 : Mean age (years) 2010 – 2014

Age 2010 2011 2012 2013 2014

All ages, Mean + SD yrs

45.6 ± 20.6 46.5± 20.7 46.6 ± 20.7 46.5 ± 20.6 45.9 + 20.6

Age ≥ 18 years Mean + SD yrs

49.4 ± 18.1 50.2± 18.0 50.3 ± 17.8 50.3 ± 17.7 49.7 + 17.8

The average age for all age groups was 45.9 + 20.6 years (median 47.7 years). For adult patients, with age exceeding 18 years, the average age was 49.7 + 17.8 years (median 51.1 years). The average age of patients admitted to ICUs has remained fairly similar over the last five years. Figure 3 : Age groups, 2014

0

1000

2000

3000

4000

5000

6000

7000

<10 10-19.9 20-29.9 30-39.9 40-49.9 50-59.9 60-69.9 >70

Age Group

Nu

mb

er

of

Ad

mis

sio

ns.

....

....

......

.

Geriatric patients (age 65 years and above) and paediatric patients (age less than 12 years) accounted for 20.6% and 4.0% of total admissions respectively in 2014.

35

Table 7 : Ethnic groups 2014

Ethnic group n %

Malay 21761 56.1

Chinese 6289 16.2

Indian 4068 10.5

Bumiputra Sabah/Sarawak 2968 7.6

Foreigner 2724 7.0

Other Malaysian 744 1.9

Orang Asli 227 0.6

Unknown 24 0.1

Total 38, 805 100

Figure 4 : Ethnic groups 2014

21761

6289

40682968 2724

744 227 240

5000

10000

15000

20000

25000

Malay Chinese Indian Bumiputra

(Sabah/Sarawak)

Foreigner Other MalaysianOrang Asli Unknown

The distribution of patients admitted to ICU reflected the distribution of the ethnic groups in the general population in Malaysia. Foreigners contributed 7% to the overall ICU admissions.

36

Table 8 : Length of ICU stay, by individual hospital 2010 – 2014 Hospital

Mean (Median), days

2010 2011 2012 2013 2014

AS 4.1 (2.2) 4.6 (2.8) 5.6 (3.1) 4.9 (2.9) 4.6 (2.8)

PP 5.6 (2.8) 5.1 (2.5) 5.4 (2.6) 5.9 (2.7) 6.2 (2.9)

IPH 5.0 (2.6) 5.3 (2.6) 5.5 (2.9) 5.9 (3.0) 6.1 (3.2)

KL 4.7 (2.5) 4.7 (2.8) 5.1 (2.8) 5.0 (2.7) 4.6 (2.4)

SLG 4.4 (2.1) 4.4 (2.4) 4.5 (2.6) 4.2 (2.0) 4.7 (2.5)

KLG 4.9 (2.7) 3.6 (2.0) 4.1 (2.1) 4.3 (1.9) 4.0 (2.0)

SBN 5.1 (2.8) 4.8 (2.7) 4.9 (2.7) 5.9 (2.9) 5.0 (2.7)

MLK 4.1 (2.1) 4.0 (2.7) 4.1 (2.1) 4.1 (2.1) 4.8 (2.5)

JB 5.0 (2.8) 5.2 (3.0) 5.2 (3.0) 4.7 (2.8) 5.4 (3.1)

KTN 4.4 (2.5) 6.3 (3.4) 6.3 (3.6) 5.6 (3.3) 5.5 (2.8)

KT 4.5 (2.5) 4.0 (2.3) 4.1 (2.2) 4.6 (2.7) 4.1 (2.1)

KB 4.8 (2.0) 4.7 (1.9) 4.7 (2.3) 4.9 (2.3) 4.2 (2.3)

KCH 5.0 (2.7) 5.6 (3.0) 5.2 (2.9) 4.7 (2.6) 3.9 (2.0)

KK 6.2 (3.2) 6.3 (3.7) 6.3 (3.8) 6.2 (3.6) 5.9 (3.6)

SP 4.6 (3.2) 4.0 (2.4) 7.6 (2.2) 4.7 (2.6) 4.8 (2.8)

PJY 3.6 (1.7) 3.2 (1.5) 3.2 (1.5) 3.5 (1.8) 3.9 (1.7)

MUR 3.5 (1.8) 4.8 (2.4) 3.5 (1.8) 3.0 (1.8) 3.7 (1.9)

TI 4.2 (1.8) 4.0 (2.0) 3.5 (2.1) 3.0 (1.8) 3.2 (1.7)

TPG 7.4 (3.5) 7.0 (3.7) 5.1 (2.7) 4.1 (2.7) 4.7 (2.6)

SJ 4.3 (2.3) 4.3 (2.1) 4.2 (2.1) 6.2 (3.1) 6.5 (3.5)

KJG 3.8 (2.1) 4.0 (2.7) 4.6 (2.9) 4.7 (3.2) 4.8 (3.1)

KGR 4.2 (2.2) 3.4 (1.7) 4.3 (2.1) 4.2 (2.6) 4.2 (2.1)

SJMC 2.5 (1.3) 2.4 (1.3) 2.7 (1.6) 2.6 (1.6) 2.5 (1.6)

TML 4.9 (2.8) 5.1 (3.0) 6.4 (3.5) 4.8 (2.6) 4.7 (2.7)

KP 3.5 (2.0) 5.8 (3.1) 5.7 (3.0) 5.5 (2.9) 4.7 (2.7)

SMJ 4.4 (2.2) 3.7 (2.3) 3.9 (2.5) 3.6 (2.2) 3.2 (1.9)

BP 4.8 (2.7) 4.3 (2.2) 5.7 (3.3) 4.5 (2.8) 4.4 (2.7)

TW 4.1 (2.3) 3.5 (2.2) 3.5 (2.4) 3.8 (2.5) 4.2 (2.5)

MRI 5.4 (2.8) 4.4 (2.3) 5.2 (2.5) 4.5 (2.6) 4.9 (3.0)

KLM 3.9 (2.3) 3.6 (2.0) 3.3 (1.9) 3.2 (1.7) 3.3 (1.8)

SDG 4.3 (2.1) 4.8 (2.7) 4.8 (2.8) 4.4 (2.2) 4.4 (2.4)

SB 5.3 (2.9) 4.7 (2.4) 5.1 (2.5) 5.4 (3.3) 6.8 (4.0)

DKS 6.8 (3.2) 6.0 (3.1) 5.1 (3.1) 4.5 (2.5) 3.7 (1.9)

SI 5.2 (2.3) 7.0 (3.7) 6.2 (3.3) 5.4 (2.7) 5.1 (2.6)

SBL 5.7 (2.8) 6.0 (3.2) 5.7 (3.1) 5.5 (3.1) 4.8 (2.7)

AMP 5.3 (2.9) 5.4 (3.2) 5.0 (2.9) 5.4 (2.9) 5.7 (3.0)

LIK 2.4 (1.5) 2.5 (1.6) 3.5 (1.8) 3.5 (1.9) 4.1 (2.6)

UMMC - - 7.2 (3.8) 5.6 (3.3) 5.5 (2.6)

LKW - - 5.3 (2.0) 4.1 (2.0) 3.7 (2.1)

BM - - - 9.0 (4.3) 8.8 (5.6)

SLR - - 6.3 (3.2) 6.3 (3.0) 6.6 (3.0)

PD - - 4.0 (2.5) 4.4 (2.8) 3.5 (2.0)

37

KKR - - 5.6 (2.9) 5.7 (3.4) 5.8 (3.2)

SGT - - 4.5 (2.8) 3.3 (2.3) 3.7 (2.1)

TM - - 3.5 (1.9) 3.8 (2.5) 4.5 (3.3)

KEM - - 3.3 (2.6) 4.2 (2.8) 5.0 (2.6)

KLP - - 1.3 (0.8) 2.9 (1.5) 3.0 (2.0)

LAB - - 4.6 (2.2) 4.4 (1.9) 4.1 (1.8)

KEN - - 6.5 (2.9) 5.1 (2.9) 5.4 (3.0)

BIN - - 5.4 (2.8) 3.9 (2.1) 3.9 (2.3)

LD - - 5.7 (2.7) 4.8 (2.7) 5.1 (3.4)

Total 4.7 (2.4) 4.7 (2.4) 4.8 (2.6) 4.7 (2.5) 4.7 (2.5)

The average length of ICU stay in 2014 was 4.7 days. This has not changed much over the past 5 years. The median length of stay was 2.5 days. SJMC recorded the shortest length of stay (2.5 days). Among the MOH ICUs, KLP had the shortest average length of stay (3.0 days). BM recorded the longest length of ICU stay (8.8 days).

38

Table 9 : Length of hospital stay, by individual hospital 2010 – 2014 Hospital

Mean (Median), days

2010 2011 2012 2013 2014

AS 13.4 (8.3) 14.5 (9.5) 15.1 (9.2) 14.6 (8.8) 13.1 (7.9)

PP 21.1 (12.0) 19.0 (11.5) 19.5 (12.0) 19.2 (12.0) 20.2 (12.5)

IPH 14.6 (9.4) 15.4 (9.3) 16.0 (10.6) 15.2 (9.8) 15.3 (10.0)

KL 17.8 (10.3) 19.1 (11.0) 17.7 (10.7) 16.5 (10.2) 14.8 (8.6)

SLG 15.3 (9.8) 16.7 (11.0) 17.3 (12.1) 15.2 (10.5) 15.2 (9.9)

KLG 14.1 (9.6) 13.6 (8.4) 12.2 (7.6) 12.5 (7.80 11.5 (7.4)

SBN 16.7 (10.1) 19.9 (11.0) 17.0 (10.6) 18.5 (10.7) 17.5 (10.4)

MLK 13.6 (8.3) 14.2 (9.3) 16.0 (10.0) 14.4 (8.6) 16.2 (9.6)

JB 14.2 (9.8) 14.6 (10.1) 14.7 (9.9) 13.6 (9.3) 14.2 (9.4)

KTN 14.9 (10.0) 17.1 (12.1) 18.0 (12.3) 15.8 (10.8) 16.6 (10.4)

KT 12.7 (8.9) 12.6 (8.3) 14.5 (9.7) 14.6 (9.80 13.5 (8.8)

KB 16.6 (10.1) 14.5 (10.0) 16.5 (10.0) 14.4 (9.6) 12.0 (8.0)

KCH 19.6 (12.8) 20.5 (12.6) 21.4 (13.7) 19.2 (12.1) 19.5 (11.8)

KK 21.0 (13.2) 21.4 (14.1) 19.9 (11.7) 17.7 (11.1) 16.4 (10.9)

SP 12.8 (8.3) 10.8 (7.4) 14.0 (8.2) 12.9 (8.9) 12.6 (8.4)

PJY 11.7 (8.1) 11.6 (8.0) 11.7 (8.6) 13.2 (8.2) 12.4 (7.4)

MUR 13.3 (8.3) 16.3 (10.3) 22.0 (10.5) 13.6 (8.4) 13.6 (9.1)

TI 12.4 (8.0) 12.5 (8.4) 14.2 (9.6) 11.4 (8.2) 11.3 (7.5)

TPG 14.3 (8.7) 15.1 (10.3) 12.6 (8.3) 10.7 (7.8) 11.7 (8.0)

SJ 11.4 (8.4) 12.9 (9.1) 13.0 (8.2) 14.3 (9.7) 15.9 (11.1)

KJG 12.2 (7.6) 11.2 (7.9) 13.5 (8.3) 12.5 (8.6) 13.4 (8.7)

KGR 12.7 (8.1) 12.6 (8.2) 18.3 (10.9) 14.2 (9.7) 13.8 (7.9)

SJMC 7.3 (5.1) 7.7 (5.3) 8.4 (5.1) 7.7 (4.6) 7.7 (4.8)

TML 13.8 (9.0) 14.6 (9.9) 14.5 (10.7) 13.1 (9.3) 11.9 (8.0)

KP 12.1 (6.0) 12.8 (8.7) 15.5 (9.3) 13.6 (8.5) 13.3 (8.0)

SMJ 12.5 (8.0) 12.1 (7.1) 12.0 (7.2) 10.5 (7.1) 8.4 (6.1)

BP 13.1 (8.3) 11.4 (8.0) 13.6 (9.5) 14.0 (9.0) 15.9 (9.7)

TW 14.1 (9.0) 15.3 (9.1) 13.0 (8.4) 14.1 (9.1) 13.5 (8.6)

MRI 16.6 (10.6) 15.0 (9.6) 14.0 (10.8) 12.4 (9.9) 13.1 (10.0)

KLM 10.6 (7.4) 11.4 (7.3) 12.6 (7.8) 11.7 (7.9) 11.6 (7.6)

SDG 14.6 (8.8) 14.7 (9.0) 14.6 (9.4) 14.3 (8.1) 13.2 (7.5)

SB 15.4 (9.0) 13.1 (8.1) 13.1 (8.3) 15.7 (10.5) 15.3 (10.0)

DKS 15.8 (9.0) 13.7 (10.1) 12.4 (8.2) 11.4 (7.6) 11.8 (6.8)

SI 16.6 (10.9) 19.7 (12.2) 16.0 (9.7) 14.6 (9.2) 15.3 (9.3)

SBL 17.1 (9.8) 19.5 (11.2) 19.2 (10.8) 17.0 (9.8) 15.4 (7.9)

AMP 15.6 (9.0) 15.1 (10.2) 15.4 (10.5) 15.1 (10.7) 16.1 (10.5)

LIK 11.8 (8.1) 11.6 (7.6) 18.4 (9.7) 15.3 (10.9) 15.0 (10.6)

UMMC - - 25.2 (16.2) 22.0 (12.4) 19.7 (11.4)

LKW - - 12.7 (6.4) 12.5 (6.6) 10.5 (5.9)

BM - - 20.9 (10.1) 16.3 (10.3) 14.8 (11.5)

SLR - - 12.1 (7.9) 12.2 (6.6) 13.3 (8.2)

PD - - 10.2 (5.9) 10.9 (7.4) 10.2 (5.9)

39

KKR - - 12.5 (9.6) 13.6 (8.6) 11.4 (7.0)

SGT - - 14.8 (8.3) 10.4 (7.1) 10.7 (7.6)

TM - - 12.0 (8.2) 9.1 (6.3) 12.5 (7.3)

KEM - - 9.6 (7.8) 12.3 (8.0) 11.9 (8.0)

KLP - - 6.3 (6.9) 11.4 (6.9) 11.3 (7.5)

LAB - - 14.4 (6.4) 10.0 (4.3) 9.4 (5.9)

KEN - - 19.2 (10.4) 15.0 (9.6) 15.1 (10.4)

BIN - - 21.5 (12.6) 14.2 (10.3) 13.4 (7.9)

LD - - 12.8 (7.7) 13.2 (8.3) 14.2 (9.5)

Total 14.6 (9.0) 14.9 (9.3) 15.5 (9.5) 14.4 (9.0) 14.2 (8.7)

The average length of hospital stay was 14.2 days with a median of 8.7 days. PP recorded the longest length of hospital stay of 20.2 days. This was followed by UMMC and KCH which had length of hospital stays of 19.7 and 19.5 days respectively. Among MOH hospitals, SMJ recorded the shortest length of hospital stay of 8.4 days. SJMC recorded a length of hospital stay of 7.7 days.

40

Table 10 : Referring units, by category of ICU 2014 Referring units

ICUs

Adm > 1000

n (%)

Adm 500 - 999

n (%)

Adm < 500

n (%)

Private

n (%)

UMMC

n (%)

Total n (%)

Medicine 11095 (50.0)

4095 (50.9)

3463 (54.2)

416 (47.8)

397 (30.6)

19466 (50.2)

General Surgery

4090 (18.4)

1950 (24.2)

1334 (20.9)

46 (5.3)

335 (25.8)

7755 (20.0)

Orthopaedic Surgery

1629 (7.3)

622 (7.7)

452 (7.1)

46 (5.3)

143 (11.0)

2892 (7.5)

O&G 1166 (5.3)

419 (5.2)

531 (8.3)

4 (0.5)

61 (4.7)

2181 (5.6)

Vascular Surgery

100 (0.5)

29 (0.4)

10 (0.2)

2 (0.2)

0 (0.0)

141 (0.4)

Paediatric Surgery

81 (0.4)

59 (0.7)

144 (2.3)

3 (0.3)

0 (0.0)

287 (0.7)

Neurosurgery 2005 (9.0)

94 (1.2)

99 (1.5)

8 (0.9)

36 (2.8)

2242 (5.8)

Plastic Surgery 173 (0.8)

14 (0.2)

35 (0.5)

1 (0.1)

19 (1.5)

242 (0.6)

ENT 479 (2.2)

164 (2.0)

97 (1.5)

26 (3.0)

42 (3.2)

808 (2.1)

Ophthalmology 18 (0.1)

6 (0.1)

3 (0.0)

0 (0.0)

2 (0.2)

29 (0.1)

Urology 238 (1.1)

25 (0.3)

0 (0.0)

19 (2.2)

47 (3.6)

329 (0.8)

Dental Surgery 104 (0.5)

25 (0.3)

17 (0.3)

0 (0.0)

0 (0.0)

146 (0.4)

Paediatric Medical

274 (1.2)

414 (5.1)

194 (3.0)

70 (8.0)

1 (0.1)

953 (2.5)

Cardiology 52 (0.2)

6 (0.1)

4 (0.1)

50 (5.7)

30 (2.3)

142 (0.4)

Haematology 41 (0.2)

86 (1.1)

1 (0.0)

16 (1.8)

20 (1.5)

164 (0.4)

Nephrology 232 (1.0%

34 (0.4)

0 (0.0)

26 (3.0)

93 (7.2)

385 (1.0)

Neurology 168 (0.8)

0 (0.0)

3 (0.0)

111 (12.8)

52 (4.0)

334 (0.9)

Cardiothoracic Surgery

11 (0.0)

2 (0.0)

0 (0.0)

3 (0.3)

3 (0.2)

19 (0.0)

Others 242 (1.1)

7 (0.1)

2 (0.0)

23 (2.6)

15 (1.2)

289 (0.7)

Total

22198 (100.0)

8051

(100.0)

6389

(100.0)

870

(100.0)

1296

(100.0)

38804 (100.0)

41

Figure 5 : Referring units, by category of ICU 2014

0%

20%

40%

60%

80%

100%

Adm ≥ 1000 Adm 500-999 Adm < 500 Private UMMC

Pe

rce

nta

ge

of

ad

mis

sio

n..

......

......

......

.....

Others

Cardiothoracic Surgery

Neurology

Nephrology

Haematology

Cardiology

Paediatric Medical

Dental Surgery

Urology

Ophthalmology

ENT

Plastic Surgery

Neurosurgery

Paediatric Surgery

Vascular Surgery

O&G

Orthopaedic Surgery

General Surgery

Medicine

The percentage of patients admitted from the medical-based disciplines increased from 29.5% in 2003 to 50.2% in 2014. Table 11 : Category of patients, by category of ICU 2014

ICUs

Adm > 1000

n (%)

Adm 500 - 999

n (%)

Adm < 500

n (%)

Private

n (%)

UMMC

n (%)

Total

n (%)

Non-operative 14692 (66.1)

5679 (70.5)

4487 (70.2)

728 (83.7)

740 (61.5)

26326 (68.0)

Elective operative

2105 (9.5

776 (9.6)

582 (9.1)

123 (14.1)

194 (16.1)

3780 (9.8)

Emergency operative

5415 (24.4)

1600 (19.9)

1326 (20.7)

19 (2.2)

269 (22.4)

8629 (22.3)

Total

22212 (100.0)

8055

(100.0)

6395

(100.0)

870

(100.0)

1203

(100.0)

38735 (100.0)

Non-operative Refers to patients in whom no surgery was done out within 7 days before ICU admission or during the first 24 hours after ICU admission

Operative-elective Refers to patient in who surgery was done within 7 days before ICU admission or during the first 24 hours after ICU admission on a scheduled basis

Operative-emergency

Refers to patient in who surgery was done within 7 days before ICU admission or during the first 24 hours after ICU admission on an unscheduled basis

42

Figure 6 : Category of patients, by category of ICU 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Adm > = 1000 Adm 500 - 999 Adm < 500 P rivate UMMC

Per

cen

tag

e o

f ad

mis

sio

ns.

....

..

E mergency operative

E lective operative

Non-operative

Table 12 : Category of patients in MOH hospitals 2010 - 2014

Category of patients 2010 (%)

2011 (%)

2012 (%)

2013 (%)

2014 (%)

Non-operative 62.9 62.0 65.1 66.1% 67.8

Elective operative 11.3 10.5 10.3 10.4% 9.4

Emergency operative 25.8 27.5 24.6 23.6% 22.8

Figure 7 : Category of patients in MOH hospitals 2004 – 2014

0

10

20

30

40

50

60

70

80

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Year

Perc

en

tag

e o

f a

dm

issio

ns ... .....

Non-operative

Elective operative

Emergencyoperative

43

The categories of patients did not differ much among MOH ICUs. The proportion of patients admitted into ICU after elective operations was higher in UMMC (16%) and private hospital (14%) compared with that of MOH ICUs (9%). Emergency operative patients admitted into the private hospital ICU were relatively low (2%) compared with MOH hospitals (23%) and UMMC (23%).

Non-operative admissions accounted for 68%, 62% and 84% of all admissions to MOH, UMMC and SJMC ICUs respectively. There was a steady increase in non-operative patients over the past 10 years with a 21% increase from 2004 to 2014, while the percentage of elective operative and emergency operative patients decreased by 9% and 12% respectively. Table 13 : Location before ICU admission, by category of ICU 2014

Location

ICUs

Adm > 1000 n (%)

Adm 500 - 999

n (%)

Adm < 500

n (%)

Private

n (%)

UMMC

n (%)

Total

n (%)

Ward 7467 33.6%

3092 38.4%

2745 42.9%

221 25.4%

368 29.7%

13893 35.8%

OT 6126 27.6%

1652 20.5%

1238 19.4%

112 12.9%

423 34.2%

9551 24.6%

Emergency department

6697 30.1%

2791 34.7%

2040 31.9%

475 54.6%

410 33.1%

12413 32.0%

Other critical areas 706 3.2%

147 1.8%

74 1.2%

5 0.6%

0 0.1%

933 2.4%

Other locations 235 1.1%

35 0.4%

18 0.3%

49 5.6%

8 0.6%

345 0.9%

Other hospitals 988 4.4%

337 4.2%

278 4.3%

8 0.9%

27 2.2%

1638 4.2%

Total

22219 100.0%

8054

100.0%

6393

100.0%

870

100.0%

1237

100.0%

38773

100.0%

Location before ICU admission: Refers to the area/location patient was being managed just before being admitted into ICU

Figure 8 : Location before ICU admission, by category of ICU 2014

0%

20%

40%

60%

80%

100%


Perc

en

tag

e o

f A

dm

issi

on

....

....

......

.... Other hospitals

Other locations

Other critical areas

ED

OT

Ward

44

Table 14 : Location before ICU admission in MOH hospitals 2010 – 2014

Location 2010

(%)

2011

(%)

2012

(%)

2013

(%)

2014

(%)

Ward 38.2 37.4 36.7 35.7 36.3

Operation theatre 29.0 29.3 26.6 26.4 24.6

Emergency department

23.9 24.0 27.9 29.7 31.4

Other critical areas 3.7 4.1 3.7 2.9 2.5

Other locations 0.9 0.5 0.7 0.6 0.8

Other hospitals 4.3 4.7 4.5 4.6 4.4

Figure 9 : Location before ICU admission in MOH hospitals 2004 – 2014

0

5

10

15

20

25

30

35

40

45

50

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Per

cent

age

of a

dm

issi

on...

......

.....

Ward

OperationTheatre

EmergencyDepartment

Other criticalareas

Other locations

Other hospital

The percentage of admissions from the emergency department had increased more than three-fold, while admissions from the operating theatre had decreased by almost half over the past 10 years. Although the percentage of direct admissions from the operating theatre had decreased, a number of patients from other areas were operative in nature, ranging from 7% of admissions from ED to 16% from other critical care areas (e.g. coronary care unit, cardiothoracic unit, neonatal/paediatric ICU, neurosurgical ICU, urological ICU, haemodialysis unit, high dependency wards, obstetric intensive care ward, ED resuscitation wards).

45

Table 15: Main organ failure on ICU admission, by category of ICU 2014

Main organ failure

ICUs

Adm ≥ 1000 n (%)

Adm 500 - 999

n (%)

Adm < 500

n (%)

Private

n (%)

UMMC

n (%)

Total

n (%)

Without organ failure

6247 31.8%

2177 32.8%

1716 33.4%

556 75.7%

497 38.8%

11193 33.5%

Respiratory 3387

17.3% 861

13.0% 1182

23.0% 1

0.1%

105 8.2%

5536 16.6%

Cardiovascular 5022

25.6% 1594

24.0% 952

18.5% 2

0.3%

407 31.7%

7977 23.9%

Neurological 2212

11.3% 1099

16.6% 674

13.1% 10

1.4%

103 8.0%

4098 12.3%

Renal 1296 6.6%

480 7.2%

373 7.3%

43 5.9%

98 7.6%

2290 6.9%

Haematological 1303 6.6%

359 5.4%

199 3.9%

118 16.1%

65 5.1%

2044 6.1%

Hepatic 148

0.8% 67

1.0% 47

0.9% 4

0.5%

7 0.5%

273 0.8%

Total 19615 (100.0)

6637 (100.0)

5143 (100.0)

734 (100.0)

1282 (100.0)

33411 (100.0)

The definition of organ failure is based on the Sequential Organ Failure Assessment (SOFA) [4]

Main organ failure: Refers to the main or most important organ failure within 24 hours of ICU admission and management.

.

Figure 10 : Main organ failure on ICU admission, by category of ICU 2014

0%

20%

40%

60%

80%

100%


Perc

en

tag

e o

f A

dm

issio

n Haematologicalfailure

Hepatic failure

Renal failure

Neurological failure

Cardiovascularfailure

Respiratory failure

No organ failure

In MOH ICUs, cardiovascular failure (36%) was the most common organ failure during the first 24 hours of ICU admission followed by respiratory (25%), neurological (19%), renal (10%), haematological (9%) and hepatic (1%).

46

Table 16 : Number of organ failure(s) on ICU admission, by category of ICU 2014

Main organ failure

ICUs

Adm ≥ 1000

n (%)

Adm 500 - 999

n (%)

Adm < 500

n (%)

Private

n (%)

UMMC

n (%)

Total

n (%)

Without 6380 (32.5) 2233 (33.6) 1796 (34.9) 559 (76.2) 502 (39.2) 11470 (34.3)

Single 6140 (31.3) 2126 (32.0) 1506 (29.3) 172 (23.4) 362 (28.2) 10306 (30.8)

Two 4381 (22.3) 1317 (19.8) 1071 (20.8) 3 (0.4) 249 (19.4) 7021 (21.0)

Three 2097 (10.7) 694 (10.5) 545 (10.6) 0 (0.0) 126 (9.8) 3462 (10.4)

Four 532 (2.7) 216 (3.3) 188 (3.7) 0 (0.0) 38 (3.0) 974 (2.9)

Five 79 (0.4) 44 (0.7) 32 (0.6) 0 (0.0) 5 (0.4) 160 (0.5)

Six 6 (0.0) 7 (0.1) 5 (0.1) 0 (0.0) 0 (0.0) 18 (0.1)

Total 19615 (100.0) 6637 (100.0) 5143 (100.0) 734 (100.0) 1282 (100.0) 33411 (100.0)

Figure 11: Number of organ failure(s) on ICU admission by category of ICU, 2014

0%

20%

40%

60%

80%

100%


Perc

en

tag

e o

f A

dm

issi

on

.......

......

Six

Five

Four

Three

Two

One

None

In 2014, about two-thirds (66%) of the patients were admitted with one or more organ failures in MOH ICUs. 47% of these patients had single organ failure. 32%, 16%, 4%, 0.7% and 0.1% had two, three, four, five and six organ failures respectively.

47

Table 17 : Ten most common diagnoses leading to ICU admission 2014 Diagnosis

Number Percentage

Hospitals with admission > 1000 Dengue 2469 11.1

Sepsis 1744 7.9

Head Injury 1570 7.1

Community acquired pneumonia 1119 5.0

Cerebrovascular disease (infarct, thrombosis, haemorrhage) 879 4.0

Bronchial asthma 646 2.9

Non-cardiogenic pulmonary oedema 640 2.9

Infection/gangrene of limb (including osteomyelitis, necrotizing fasciitis) 619 2.8

Diabetic ketoacidosis / diabetic hyperosmolar hyperglycaemic state (HHS) 599 2.7

Chronic lower respiratory disease 563 2.5

Hospitals with admission 500 – 999 Sepsis 691 8.5

Head injury 538 6.7

Dengue 520 6.5





Infection / gangrene of limb (including osteomyelitis, necrotizing fasciitis) 212 3.1

Gastrointestinal perforation (including anastomotic leak) 194 2.4


Hospitals with admission < 500 Community acquired pneumonia 497 7.8

Sepsis 425 6.7

Head injury 341 5.3

Dengue 272 4.2



Ischaemic heart disease / acute coronary syndrome 208 3.2



Gastrointestinal perforation (including anastomotic leak) 157 2.5

Private Hospital Dengue 221 25.4

Cerebrovascular disease (infarct, thrombosis, haemorrhage) 84 9.7

Other abdominal / pelvic conditions 55 6.3

Seizures ( primary, no structural brain disease) 37 4.3

Gastrointestinal bleeding 35 4.0

48

Sepsis 34 3.9

Other respiratory conditions 33 3.8

Other cardiovascular conditions 24 2.8

ENT / oral conditions 24 2.8


UMMC Sepsis 197 14.7

Dengue 68 5.1

Other renal / genito-urinary conditions (UV prolapse, TURP syndrome) 58 4.3



Gastrointestinal malignancy 42 3.1


Hepatobiliary disease 38 2.8

Head injury 33 2.5


Figure 12 : Ten most common diagnoses leading to ICU admission in MOH Hospitals, 2014

919

1041

1045

1048

1106

1191

2064

2509

2860

3482

0 500 1000 1500 2000 2500 3000 3500

Number of admissions

Diabetic ketoacidosis/Diabetic HHS

Infection/Gangrene of limb

Non-cardiogenic pulmonary oedema

Bronchial asthma

Chronic lower respiratory disease

Cerebrovascular disease

Community acquired pneumonia

Head injury

Sepsis

Dengue infection

For the first time, since the inception of this registry, dengue infection was the most common diagnosis leading to ICU admission in 2014. This was followed by sepsis, head injury and community-acquired pneumonia. The latter three were the three most common diagnoses leading to ICU admission over the last 10 years until 2013.

.

49

Table 18 : Ten most common diagnoses leading to ICU admission using APACHE II diagnostic category 2014 Diagnosis

Number Percentage

Hospitals with admission > 1000

Non-operative: Cardiovascular failure from sepsis 2646 11.9

Non-operative: Respiratory failure from Infection 1975 8.9

Non-operative: Respiratory system as principal reason for admission 1574 7.1

Non-operative: Haemorrhagic shock / hypovolemia 1532 6.9

Operative: Respiratory system as principal reason for admission 1117 5.0

Non-operative: Neurologic system as principal reason for admission 801 3.6

Non-operative: Multiple trauma 781 3.5

Non-operative: Metabolic / renal system as principal reason for admission

750 3.4

Operative: Multiple trauma 643 2.9

Non-operative: Pulmonary oedema (non-cardiogenic) 626 2.8

Hospitals with admission 500 – 999


Non-operative: Respiratory failure from infection 906 11.2


Non-operative: Metabolic/ renal system as principal reason for admission

379 4.7

Non-operative: Head trauma 329 4.1

Operative: Respiratory insufficiency after surgery 277 3.4



Operative: Cardiovascular system as principal reason for admission 320 3.7

Operative: Gastrointestinal perforation / obstruction 248 3.5


Hospitals with admission < 500





Non-operative: Pulmonary oedema (non-cardiogenic) 221 3.5


Non-operative: COPD 177 2.8


278 3.9

Operative: Respiratory insufficiency after surgery 165 2.6

Non-operative: Head trauma 165 2.6

Private Hospital




96 11.0



50

Operative: Gastrointestinal system as principal reason for admission 37 4.3

Non-operative: Gastrointestinal system as principal reason for admission

36 4.1

Non-operative: Gastrointestinal bleeding 33 3.8

Non-operative: Cardiovascular system as principal reason for admission

32 3.7


Non-operative: Seizure disorder 30 3.4

UMMC





Non-operative: Cardiovascular system as principal reason for admission

72 6.0



Operative: GI surgery for neoplasm 57 4.2


50 3.7


Table 19 : Severe sepsis, ARDS and AKI within 24hrs of ICU admission 2014

ICUs

Adm ≥ 1000

n (%)

Adm 500 - 999

n (%)

Adm < 500 n (%)

Private

n (%)

UMMC

n (%)

Total

n (%)

Severe sepsis* 4847 (21.8) 1405 (17.5) 1031 (16.1) 3 (0.3) 475 (35.4) 7761 (20.0)

ARDS# 1964 (8.9) 739 (9.2) 574 (9.0) 3 (0.3) 126 (9.4) 3406 (8.8)

AKI^ 3443 (15.5) 1288 (16.0) 916 (14.3) 3 (0.3) 270 (20.1) 5920 (15.2)

* Sepsis refers to documented infection with 2 out of 4 SIRS criteria:

1) Temperature >38.3 or < than 36C 2) Total white cell count > 12000 or < 4000 3) Heart rate > 90/min 4) Respiration rate > 20 breath / minute or PaCO2 < 32mmHg

Severe sepsis is sepsis with one of the following organ dysfunction:

(1) Hypotension: Systolic blood pressure < 90 mmHg or mean arterial pressure < 70 mm Hg (2) PaO2/FIO2 ≤ 300 mmHg (3) Acute decrease in platelet count to < 100 000 u/L (4) Acute increase in total bilirubin to > 70 umol/L (5) Acute increase in serum creatinine to >170umol/L or urine output < 0.5 mL/kg/hour for > 2 hours (6) Serum lactate >4 mmol/l

# ARDS refers to a severe form of acute lung injuryI with a PaO2/FIO2 ratio ≤ 200 mm Hg with diffuse radiologic infiltrates which is not predominantly due to heart failure ^AKI : Serum creatinine x 2 baseline or urine output < 0.5 ml/kg/hr x 12 hours

51

Table 20 : Severe sepsis, ARDS and AKI within 24hrs of ICU admission, by individual hospital 2012 – 2014

Hospital

2012 2013 2014

Severe sepsis n (%)

ARDS

n (%)

AKI

n (%)

Severe sepsis n (%)

ARDS n (%)

AKI n (%)

Severe sepsis n (%)

ARDS n (%)

AKI n (%)

AS 410

(34.3) 278

(23.2) 213

(17.8) 380

(28.3) 198

(14.7) 227

(16.9) 394

(29.7) 200

(15.1) 290

(21.9)

PP 449

(34.9) 115 (8.9)

397 (30.9)

413 (36.8)

58 (5.2)

377 (33.6)

370 (32.6)

35 (3.1)

293 (25.8)

IPH 60

(6.6) 61

(6.6) 46

(5.0) 149

(12.4) 87

(7.2) 129

(10.8) 148

(12.2) 123

(10.1) 197

(16.2)

KL 1073 (54.5)

192 (9.8)

589 (29.9)

727 (38.2)

46 (2.4)

245 (12.9)

694 (32.4)

26 (1.2)

269 (12.6)

SLG 352

(27.3) 106 (8.2)

228 (17.7)

409 (27.1)

190 (12.6)

259 (17.2)

270 (18.9)

189 (13.3)

232 (16.3)

KLG 208 (9.7)

22 (1.0)

122 (5.7)

491 (23.8)

346 (16.8)

229 (11.1)

925 (40.6)

405 (17.8)

353 (15.5)

SBN 153

(28.5) 141

(26.3) 90

(16.8) 134

(28.5) 133

(28.2) 95

(20.2) 289

(53.6) 130

(24.1) 141

(26.2)

MLK 93

(5.5) 13

(0.8) 125

(7.4) 10

(0.6) 1

(0.1) 30

(1.8) 37

(2.6) 7

(0.5) 26

(1.8)

JB 478

(27.3) 71

(4.1) 364

(20.8) 557

(28.9) 95

(4.9) 465

(24.1) 510

(30.2) 68

(4.0) 391

(23.2)

KTN 117

(18..3) 66

(10.3) 127

(19.8) 201

(24.0) 109

(13.0) 180

(21.5) 254

(23.9) 146

(13.8) 230

(21.7)

KT 7

(0.5) 1

(0.1) 2

(0.1) 11

(0.9) 3

(0.3) 55

(4.7) 7

(0.6) 3

(0.3) 53

(4.5)

KB 155

(12.1) 185

(14.4) 174

(13.5) 168

(12.6) 241

(18.0) 234

(17.5) 92

(5.7) 232

(14.4) 198

(12.3)

KCH 111

(13.0) 14

(1.6) 59

(6.9) 122

(12.8) 9

(0.9) 48

(5.1) 121

(10.6) 8

(0.7) 63

(5.5)

KK 248

(26.0) 390

(40.9) 164

(17.2) 348

(34.1) 293

(28.7) 243

(23.8) 226

(22.9) 139

(14.1) 230

(23.3)

SP 19

(11.9) 1

(0.6) 10

(6.3) 92

(15.8) 20

(3.4) 72

(12.3) 14

(1.5) 6

(0.6) 88

(9.2)

PJY 63

(11.0) 54

(9.4) 57

(8.0) 115

(19.0) 91

(15.0) 91

(15.0) 126

(19.3) 90

(13.8) 112

(17.2)

MUR 7

(1.1) 22

(3.5) 51

(8.0) 16

(2.4) 44

(6.5) 45

(6.7) 10

(1.7) 96

(16.0) 37

(6.2)

TI 65

(17.0) 88

(22.9) 48

(12.5) 24

(6.0) 5

(1.2) 38

(9.5) 68

(16.8) 2

(0.5) 77

(19.0)

TPG 788

(65.5) 18

(1.5) 57

(4.7) 650

(48.2) 18

(1.3) 99

(7.3) 249

(21.1) 37

(3.1) 108 (9.1)

SJ 138

(21.4) 29

(4.5) 113

(17.5) 97

(23.5) 29

(7.0) 72

(17.5) 132

(32.6) 19

(4.7) 73

(18.0)

KJG 14

(3.8) 9

(2.4) 16

(4.3) 8

(2.5) 1

(0.3) 23

(7.2) 16

(5.6) 3

(1.1) 36

(12.7)

KGR 6

(1.7) - - 11

(3.4) 0

(0.0) 3

(0.9) 6

(1.8) 2

(0.6) 10

(2.9)

SJMC 7

(0.5) 12

(0.8) 15

(1.0) 12

(0.9) 9

(0.7) 7

(0.5) 3

(0.3) 3

(0.3) 3

(0.3)

TML 48

(11.0) 21

(4.8) 57

(13.1) 56

(9.3) 11

(1.8) 112

(18.8) 62

(7.4) 34

(4.1) 127

(15.2)

KP 110

(32.9) 14

(4.2) 83

(24.9) 142

(36.0) 22

(5.6) 77

(19.6) 208

(40.6) 21

(4.1) 95

(18.6)

52

SMJ 0

(0.0) 1

(0.2) 2

(0.5) 2

(0.5) 1

0.3) 2

(0.5) 0

(0.0) 0

(0.0) 1

(0.2)

BP 86

(20.7) 57

(13.7) 85

(20.5) 75

(16.4) 8

(1.7) 42

(9.2) 56

(12.2) 15

(3.3) 57

(12.4)

TW 84

(19.4) 55

(12.7) 66

(15.3)

30 (6.7) 45

(10.0) 54

(12.1) 49

(9.8) 32

(6.4) 29

(5.8)

MRI 30

(6.3) 7

(1.5) 5

(1.1) 78

(16.2) 6

(1.2) 35

(7.3) 53

(12.4) 10

(2.3) 66

(15.4)

KLM 94

(15.6) 32

(5.3) 28

(4.7) 70

(12.5) 36

(6.4) 47

(8.4) 96

(17.3) 48

(8.6) 75

(13.5)

SDG 51

(5.8) 260

(29.7) 158

(18.1) 75

(8.8) 117

(13.8) 141

(16.6) 111

(13.3) 24

(2.9) 193

(23.1)

SB 78

(15.9) 38

(7.8) 95

(19.5) 72

(14.3) 47

( 9.3) 82

(16.2) 68

(15.8) 33

(7.7) 80

(18.6)

DKS 67

(12.7) 26

(4.9) 53

(10.1) 100

(10.4) 48

(5.0) 65

(6.8) 37

(3.9) 12

(1.3) 45

(4.7)

SI 277

(34.6) 76

(9.5) 156

(19.5) 275

(28.6) 116

(12.1) 156

(16.2) 319

(28.6) 62

(5.6) 219

(19.7)

SBL 199

(12.6) 111

(7.0) 230

(14.6) 160 (8.3)

92 (4.8)

321 (16.8)

457 (20.0)

423 (18.6)

521 (22.9)

AMP 295

(51.6) 187

(32.7) 102

(17.8) 235

(41.5) 120

(21.2) 126

(22.3) 226

(35.7) 139

(22.0) 145

(22.9)

LIK 18

(6.7) 7

(2.6) 10

(3.7) 5

(1.0) 11

(2.1) 8

(1.6) 7

(2.0) 8

(2.3) 4

(1.1)

UMMC 136

(28.8) 75

(15.8) 135

(28.5) 225

(25.9) 99

(11.4) 210

(24.1) 475

(35.4) 126 (9.4)

270 (20.1)

LKW 45

(28.7) 30

(19.1) 40

(25.5) 21

(11.7) 10

(5.6) 17

(9.4) 19

(11.6) 13

(7.9) 31

(18.9)

BM 3 (7.9) 0 (0.0) 7 (18.4) 17 (11.1) 3 (2.0) 6 (4.0) 16 (11.5) 13 (9.4) 21 (15.1)

SLR 43

(27.9) 27

(17.5) 37

(24.0) 40

(17.9) 15

(6.7) 45

(20.2) 80

(35.9) 72

(32.4) 103

(46.2)

PD 40 (19.6) 2 (1.0) 27 (13.2) 16 (6.5) 1 (0.4) 38 (15.5) 1(0.4) 0 (0.0) 5 (1.9)

KKR 6 (4.0) 7 (4.7) 16 (10.7) 64 (26.9) 59 (24.9) 39 (16.3) 82 (31.8) 90 (34.7) 40 (15.6)

SGT 34 (27.0) 10 (7.9) 33 (26.2) 24 (15.1) 16 (10.1) 37 (23.4) 29 (19.3) 20 (13.3) 33 (22.1)

TM 0 (0) 1 (5.9) 1 (5.9) 21 (16.5) 15 (11.8) 16 (12.7) 15 (9.4) 44 (27.5) 17 (10.6)

KEM 7 (7.4) 5 (5.3) 10 (10.6) 12 (11.4) 4 (3.8) 6 (5.8) 5 (5.5) 4 (4.4) 8 (8.9)

KLP 0 (0) 0 (0) 0 (0) 10 (8.6) 3 (2.6) 21 (18.1) 10 (10.5) 2 (2.1) 10 (10.5)

LAB 17(15.9) 15 (1 4.0) 11 (10.3) 28 (17.0) 23 (14.0) 25 (15.2) 46 (27.7) 70 (42.2) 42 (25.3)

KEN 8 (9.9) 7 (8.6) 5 (6.2) 31 (19.3) 6 (3.7) 36 (22.4) 36 (25.0) 5 (3.5) 39 (27.1)

BIN 51

(23.9) 67

(31.6) 29

(13.6) 96

(36.9) 4 2

(16.2) 43

(16.5) 188

(66.7) 68

(24.0) 70

(24.8)

LD 30 (18.0) 24 (14.3) 45 (26.8) 46 (19.2) 37 (15.4) 56 (23.2) 49 (22.7) 49 (22.7) 64 (29.5)

Total 6878 (20.3)

3050 (9.0)

4593 (13.6)

7171 (19.2)

3039 (8.1)

5129 (13.7)

7761 (20.0)

3406 (8.8)

5920 (15.2)

During the first 24 hours of ICU admission, 20.0%, 8.8% and 15.2% of patients had severe sepsis, acute respiratory distress syndrome and acute kidney injury respectively. The rates appear to follow a similar trend over the past three years. In the Sepsis Occurrence in Acutely Ill Patients (SOAP) study, 24% of patients had sepsis on admission [5]. An Italian study in 2011, demonstrated that 42.7% of patients had AKI within 24 hours of ICU admission [6].

53

Table 21 : SAPS II score, by individual hospital 2010 – 2014

Hospital SAPS II score (mean)

2010 2011 2012 2013 2014

AS 42.4 39.4 40.1 39.4 41.0

PP 34.9 38.0 36.5 35.8 36.1

IPH 33.7 33.0 32.0 34.0 34.2

KL 34.5 38.3 38.9 40.4 36.8

SLG 33.2 34.5 36.0 35.7 34.2

KLG 34.5 38.2 36.9 35.3 33.1

SBN 38.0 39.2 39.2 37.3 35.0

MLK 31.9 33.4 36.8 31.8 33.5

JB 38.2 39.1 40.7 31.8 40.2

KTN 33.4 34.5 39.8 38.6 37.1

KT 36.2 39.0 41.5 42.0 40.2

KB 30.0 33.4 34.4 34.3 29.6

KCH 32.4 35.0 33.0 33.7 31.4

KK 37.4 36.4 33.2 35.1 40.6

SP 41.0 40.1 43.3 39.7 37.9

PJY 29.6 28.7 28.0 29.5 32.0

MUR 32.1 37.9 37.6 38.4 39.8

TI 42.6 41.7 41.1 43.7 43.0

TPG 43.5 42.2 40.4 39.7 39.4

SJ 40.6 40.3 38.9 41.9 38.3

KJG 34.9 36.0 31.7 32.9 31.7

KGR 36.3 33.9 35.3 36.6 30.9

SJMC 18.3 18.0 18.8 18.6 16.6

TML 38.3 37.3 34.5 31.5 33.7

KP 43.0 40.0 41.2 39.9 37.3

SMJ 39.6 38.8 40.0 40.5 39.8

BP 41.0 43.3 43.4 40.1 41.0

TW 51.4 40.0 41.4 38.8 33.1

MRI 33.5 34.9 35.5 35.6 35.6

KLM 41.0 42.8 42.7 44.6 45.0

SDG 35.5 37.6 41.9 40.8 40.9

SB 39.6 39.2 40.4 43.9 41.7

DKS 51.0 41.3 38.0 39.3 37.7

SI 40.1 38.3 38.1 38.4 33.2

SBL 33.2 37.6 39.1 31.5 34.4

AMP 45.9 46.5 48.6 45.9 45.9

LIK 17.0 21.6 21.1 15.2 15.5

UMMC - - 36.5 36.5 37.4

LKW - - 41.2 29.3 39.2

BM - - 42.8 47.5 54.4

SLR - - 47.9 38.8 46.5

54

PD - - 31.3 33.8 28.3

KKR - - 36.0 44.0 44.3

SGT - - 39.9 43.8 45.1

TM - - 25.3 35.9 39.6

KEM - - 39.2 38.7 38.3

KLP - - 8.4 26.9 29.7

LAB - - 40.0 45.7 56.3

KEN - - 44.9 34.3 37.3

BIN - - 33.5 32.4 36.6

LD - - 48.8 43.3 45.1

Total 35.1 36.1 37.3 36.5 36.3

The average SAPS II score has remained the same over the past five years. The average SAPS II score in MOH hospitals for 2014 was 36.3; which carries predicted in-hospital mortality of 30.4% [8].

Table 22 : Sequential Organ Failure Assessment (SOFA) [4] by individual hospital 2010 – 2014

Hospital

SOFA score Mean (Median)

2010 2011 2012 2013 2014

AS 8.0 (8) 7.3 (7) 7.3 (7) 7.1 (7) 7.4 (7)

PP 6.3 (6) 6.2 (5) 6.7 (6) 6.9 (6) 7.1 (7)

IPH 5.9 (5) 5.4 (5) 5.4 (5) 5.9 (5) 6.1 (5)

KL 6.4 (6) 6.5 (6) 7.0 (7) 7.2 (7) 6.9 (6)

SLG 6.3 (5) 6.5 (6) 6.7 (6) 6.8 (6) 6.6 (6)

KLG 6.6 (6) 7.5 (7) 7.4 (7) 7.0 (7) 6.7 (6)

SBN 6.9 (6) 7.1 (7) 7.0 (7) 7.3 (7) 6.7 (6)

MLK 5.6 (5) 5.6 (5) 6.1 (6) 5.1 (4) 4.6 (4)

JB 7.4 (7) 7.2 (7) 7.4 (7) 7.6 (7) 7.3 (7)

KTN 5.7 (5) 5.9 (5) 7.0 (7) 7.0 (6) 6.3 (6)

KT 6.0 (6) 6.1 (6) 6.6 (6) 6.8 (7) 6.6 (6)

KB 4.7 (3) 5.1 (4) 5.3 (4) 5.5 (5) 4.6 (4)

KCH 5.6 (4) 6.0 (5) 5.4 (4) 5.7 (5) 5.0 (4)

KK 6.0 (5) 6.0 (6) 5.7 (5) 6.2 (6) 6.7 (6)

SP 6.8 (6) 6.9 (6) 6.8 (6) 7.0 (6) 7.3 (7)

PJY 4.2 (3) 4.1 (3) 4.2 (3) 5.0 (4) 5.1 (4)

MUR 5.1 (4) 5.9 (6) 5.5 (5) 5.5 (5) 6.0 (5)

TI 8.0 (8) 7.3 (7) 7.4 (7) 7.8 (7) 8.1 (7)

TPG 8.2 (8) 7.6 (8) 7.1 (7) 6.8 (6) 7.0 (7)

SJ 6.3 (6) 6.6 (6) 6.2 (6) 7.3 (7) 6.2 (5)

KJG 6.0 (5) 7.3 (7) 5.6 (5) 6.1 (5) 6.1 (6)

KGR 5.9 (5) 5.5 (4) 5.5 (5) 5.6 (5) 4.7 (4)

55

SJMC 1.3 (0) 1.4 (0) 1.4 (0) 1.1 (0) 1.4 (1)

TML 6.4 (6) 6.2 (5) 6.1 (5) 5.1 (4) 5.9 (5)

KP 7.6 (7) 7.3 (7) 7.3 (7) 6.6 (6) 6.5 (6)

SMJ 7.3 (7) 6.9 (7) 7.3 (7) 7.1 (7) 7.4 (7)

BP 6.7 (6) 6.9 (6) 7.1 (7) 6.4 (6) 6.4 (6)

TW 8.8 (9) 7.2 (6) 7.2 (6) 7.4 (7) 6.2 (5)

MRI 5.2 (4) 5.5 (5) 5.9 (6) 5.8 (5) 5.0 (4)

KLM 8.4 (8) 8.5 (8) 7.8 (7) 7.3 (7) 7.1 (7)

SDG 6.3 (5) 6.5 (6) 7.2 (7) 7.2 (7) 7.6 (7)

SB 7.8 (7) 7.8(7) 7.6 (7) 7.3 (7) 7.3 (7)

DKS 9.2 (9) 6.5 (6) 5.8 (5) 5.5 (4) 5.2 (4)

SI 6.6 (6) 6.5 (6) 6.8 (6) 6.1 (5) 5.7 (5)

SBL 6.6 (7) 7.0 (8) 7.3 (8) 7.0 (7) 7.7 (7)

AMP 8.6 (9) 8.8 (9) 8.9 (9) 8.5 (8) 8.2 (8)

LIK 1.3 (0) 2.2 (1) 2.6 (1) 1.6 (0) 1.5 (0)

UMMC - - 7.6 (7) 7.4 (6) 7.0 (6)

LKW - - 5.7 (5) 3.4 (0) 5.0 (3)

BM - - 9.5 (10) 6.8 (6) 8.8 (8)

SLR - - 7.9 (8) 6.5 (6) 7.6 (8)

PD - - 4.7 (4) 4.9 (4) 4.1 (3)

KKR - - 6.8 (6) 7.5 (7) 6.6 (6)

SGT - - 6.4 (6) 6.6 (6) 7.2 (7)

TM - - 3.1 (3) 6.2 (5) 6.6 (6)

KEM - - 6.0 (5) 6.5 (6) 5.8 (4)

KLP - - 0.8 (1) 3.7 (3) 4.3 (3)

LAB - - 4.2 (2) 5.9 (6) 7.9 (8)

KEN - - 5.9 (5) 6.1 (6) 6.0 (6)

BIN - - 5.7 (5) 4.9 (4) 6.2 (5)

LD - - 8.7 (9) 7.5 (7) 8.0 (8)

Overall 6.2 (5) 6.2 (6) 6.4 (6) 6.4 (6) 6.4 (6)

The average SOFA score in 2014 was 6.4. BM had the highest score of 8.8 while SJMC had the lowest score of 1.4.

56

SECTION C:

INTERVENTIONS

57

Table 23 : Invasive ventilation, non-invasive ventilation and reintubation, by category of ICU 2014

ICUs

Adm > 1000 n (%)

Adm 500 - 999

n (%)

Adm < 500

n (%)

Private

n (%)

UMMC

n (%)

Total

n (%)

Invasive ventilation

16325 (73.4)

6061 (75.2)

4584 (71.6)

5 (0.6)

910 (67.7)

27885 (71.1)

Non-invasive ventilation

4273 (19.2)

1620 (20.1)

926 (14.5)

3 (0.3)

389 (29.1)

7211 (18.6)

Reintubation 1079 (6.6)

345 (5.7)

245 (5.4)

1 (20.0)

102 (11.2)

1772 (6.4)

Non-invasive ventilation Refers to the continuous use of a non-invasive ventilator for ≥ hour during ICU stay Reintubation Refers to reintubation after intended or accidental extubation

Figure 13 : Invasive ventilation, by category of ICU 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Perc

en

tag

e o

f a

dm

issi

on

....

....

.....

Without invasiveventilation

Invasive Ventilation

74% and 68% of ICU admissions in MOH hospitals and UMMC received invasive mechanical ventilation respectively. In contrast, majority of patients (99%) in private hospital were not mechanically ventilated

58

Figure 14 : Non-invasive ventilation, by category of ICU 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Perc

en

tag

e o

f ad

mis

sio

n................

Without non invasiveventilationNon-invasive ventilation

Figure 15 : Non-invasive ventilation, MOH hospitals 2005 – 2014

5.1 4.7

11.412.1

13.314.3 14.4

18.6

21.7 22.3

0

5

10

15

20

25

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Year

Pe

rce

nta

ge

of

no

n-i

nv

asi

ve

ve

nti

lati

on

....

....

....

....

.

The percentage of patients receiving non-invasive ventilation in MOH ICUs increased by almost six fold from 3.7% in 2004 to 22.3% in 2013. This percentage decreased to 18.6% in 2014. 29% of ICU admissions in UMMC received non-invasive ventilation while 0.3% of ICU patients in SJMC received non-invasive ventilation.

59

Figure 16 : Reintubation by category of ICU 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Perc

en

tag

e o

f ad

mis

sio

n..............

Reintubation

No

reintubation

Figure 17 : Reintubation, MOH hospitals 2004 – 2014

8.7

9.510.3

8.8

9.8

6.7 6.9 6.66.96.36.4

0

2

4

6

8

10

12

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Year

Pe

rce

nta

ge

of

ad

mis

sio

ns.

....

....

.....

The overall reintubation rate in MOH participating centres and UMMC in 2014 was 6.6% and 11.2% respectively.

60

Table 24 : Duration of invasive mechanical ventilation, by individual hospital 2010 – 2014

Hospital Mean + SD days

2010 2011 2012 2013 2014

AS 3.2 + 4.5 3.6 + 4.8 4.8 6.0 4.1 5.5 3.9 5.5

PP 4.8 + 7.6 5.1 + 7.1 5.2 7.8 5.4 7.0 5.5 7.1

IPH 4.3 + 5.9 5.3 + 7.2 5.1 6.7 5.2 8.2 3.8 6.4

KL 3.7 + 6.4 3.9 + 5.8 4.5 7.1 4.4 7.4 4.6 7.1

SLG 4.1 + 6.4 4.5 + 6.3 4.9 5.9 4.3 5.4 4.8 6.4

KLG 4.1 + 5.3 2.9 + 4.3 2.7 4.5 2.5 5.7 2.5 3.9

SBN 4.4 + 6.9 5.1 + 7.4 4.9 6.8 6.1 8.9 5.1 7.1

MLK 4.2 + 5.2 4.0 + 1.7 4.3 5.7 4.6 6.7 4.9 6.9

JB 4.2 + 5.7 4.8 + 6.3 4.9 6.2 4.3 5.5 5.1 6.6

KTN 2.9 + 3.8 4.9 + 7.1 5.6 6.9 5.0 6.5 5.1 8.2

KT 3.6 + 4.3 3.5 + 4.6 3.4 4.6 3.9 4.9 3.8 4.9

KB 3.6 + 6.0 3.9 + 7.3 3.6 6.3 4.0 6.6 3.8 6.4

KCH 4.1 + 6.2 5.4 + 7.4 5.0 7.2 4.4 6.6 3.7 6.2

KK 4.7 + 7.1 5.2 + 7.0 5.5 7.2 5.9 8.8 5.3 9.0

SP 3.6 + 4.0 3.9 + 5.3 3.9 4.0 4.3 5.9 4.2 6.2

PJY 3.0 + 5.7 3.3 + 5.5 3.1 4.9 3.5 5.4 3.6 6.9

MUR 2.9 + 4.0 5.1 + 8.1 3.8 6.8 2.9 4.4 3.5 5.1

TI 3.0 + 8.0 3.7 + 5.8 4.0 8.0 2.5 3.0 2.4 3.0

TPG 7.0 + 10.1 7.3 + 9.6 5.2 8.0 4.1 5.3 4.6 6.8

SJ 3.7 + 4.8 4.0 + 6.3 4.3 7.2 6.4 9.7 5.5 2.6

KJG 3.6 + 4.4 4.8 + 15.3 4.9 7.3 4.1 5.0 4.5 5.5

KGR 3.1 + 4.7 3.5 + 6.3 3.8 6.5 3.6 7.0 3.5 5.2

SJMC 4.2 + 5.4 2.9 + 4.7 2.5 4.1 4.8 5.1 2.9 3.2

TML 4.5 + 6.3 5.5 + 8.9 4.9 6.7 4.6 8.2 4.7 6.6

KP 2.6 + 3.5 5.6 + 8.2 5.0 7.5 4.9 7.0 4.3 5.9

SMJ 3.9 + 6.0 3.0 + 4.9 3.2 4.1 2.9 4.3 2.6 4.0

BP 4.5 + 7.0 4.4 + 6.1 5.2 6.4 4.4 6.0 4.4 5.1

TW 3.1 + 3.7 2.9 + 3.9 3.2 6.3 4.1 6.3 4.1 6.1

MRI 4.7 + 5.7 4.6 + 5.3 4.7 5.4 4.4 5.3 4.2 5.5

KLM 3.2 + 3.8 3.6 + 5.6 3.3 4.3 3.2 4.8 3.2 4.8

SDG 3.2 + 4.8 4.6 + 6.0 4.5 5.4 4.3 6.1 4.3 6.9

SB 4.6 + 7.3 5.1 + 7.0 5.3 9.1 5.5 7.7 6.2 6.8

DKS 5.8 + 8.5 6.3 + 11.2 5.2 8.1 4.3 6.2 3.3 5.2

SI 4.3 + 6.5 7.1 + 13.6 5.9 10.3 5.5 8.7 4.9 8.0

SBL 5.8 + 6.6 6.2 + 7.0 5.7 6.3 5.8 7.6 5.4 5.5

AMP 3.8 + 5.5 5.1 + 7.7 4.4 5.9 4.8 6.3 4.9 6.6

LIK 1.4 + 1.7 1.8 + 2.2 3.6 5.2 2.7 3.8 3.2 6.1

UMMC - - 8.1 11.4 6.0 8.2 6.1 8.8

LKW - - 4.2 7.6 4.2 5.9 4.1 4.5

61

BM - - - 6.2 9.1 6.6 6.4

SLR - - 5.3 6.3 5.7 8.1 6.6 10.0

PD - - 2.8 3.4 2.7 3.0 3.9 9.5

KKR - - 4.8 6.3 5.3 7.6 5.4 8.0

SGT - - 4.3 7.1 3.0 4.0 2.5 2.5

TM - - - 3.7 4.6 4.7 6.6

KEM - - - 3.1 2.2 5.2 6.1

KLP - - - 2.1 4.0 3.3 4.7

LAB - - 4.6 6.6 3.8 5.2 4.3 5.3

KEN - - - 6.7 9.8 5.2 5.7

BIN - - 6.2 8.3 4.3 5.0 3.9 4.6

LD - - 5.2 14.0 5.4 6.7 5.1 5.6

Total 4.1 + 6.1 4.6 + 7.1 4.5 6.8 4.5 6.6 4.9 6.6

The average duration of mechanical ventilation was 4.9 days in 2014. TI had the shortest duration of invasive mechanical ventilation at 2.4 days while BM had the longest at 6.6 days.

Table 25 : Renal replacement therapy and modalities of therapy,

by category of ICU 2014

ICUs

Adm ≥ 1000 n (%)

Adm 500 - 999

n (%)

Adm < 500

n (%)

Private

n (%)

UMMC

n (%)

Total

n (%)

Renal replacement therapy

3237 (14.6)

1216 (15.1)

754 (11.8)

8 (0.9)

287 (21.4)

5502 (14.2)

Modalities of therapy

Intermittent haemodialysis

2360 (65.5)

1016 (79.6)

668 (87.5)

7 (87.5)

93 (30.9)

4144 (69.6)

CRRT

1143 (31.7)

239 (18.7)

38 (5.0)

1 (12.5)

203 (67.4)

1624 (27.3)

Peritoneal dialysis

101 (2.8)

22 (1.7)

57 (7.5)

0 (15.4)

5 (1.7)

185 (3.1)

Total 3604 (100) 1277 (100) 763 (100) 8 (100) 301 (100) 5953 (100)

62

Figure 18 : Renal replacement therapy by category of ICU 2014

21.411.814.6 15.1 0.9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Per

cen

tag

e o

f a

dm

issi

on

....

....

....

....

.

No renal replacement therapy

Renal replacement therapy

Figure 19 : Modalities of renal replacement therapy, by category of ICU 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pe

rce

nta

ge

of r

en

al r

ep

la

ce

me

nt t

he

ra

py

....

....

....

....

....

..

CRRT

Intermittenthemodialysis

Peritoneal dialysis

In MOH ICUs, 14.2% of admissions received renal replacement therapy in 2014. These patients comprise of those with acute kidney injury and chronic kidney disease. The worldwide prevalence of acute renal replacement therapy in ICUs is approximately 4% or two thirds of those with acute kidney injury [9]. Half of patients (49.3%) admitted with acute kidney injury underwent renal replacement therapy. Intermittent haemodialysis and continuous renal replacement therapy were the most common modalities of renal replacement therapy performed in MOH ICUs and UMMC respectively

63

Table 26 : Tracheostomy, by category of ICU 2014

Tracheostomy: Refers to the procedure done during ICU stay

Figure 20 : Techniques of tracheostomy, by category of ICU 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Adm ≥ 1000 Adm 500-999 Adm < 500 UMMC

Pe

rce

nta

ge

of t

ra

ch

eo

sto

mie

s..................

Percutaneoustracheostomy

Surgical tracheostomty

Percutaneous tracheostomy (43%) was more commonly performed in ICUs with more than 1000 admissions. ICUs with admissions 500 to 999 had 86% of tracheostomies performed via surgical technique, 94% of whereas ICUs with less than 500 admissions had tracheostomies performed via surgical technique. UMMC had 20%of tracheostomies performed percutaneously.

ICUs

Adm ≥ 1000 n (%)

Adm 500 - 999

n (%)

Adm < 500

n (%)

Private

n (%)

UMMC

n (%)

Total

n (%)

Tracheostomy 1700

10.4% 434

7.2% 391

8.6% 0

0.0 % 93

10.2% 2618 9.4%

Tracheostomy technique

Surgical 974

57.3% 371

85.5% 369

94.4% 0

0.0% 74

79.6% 1788

68.3%

Percutaneous 726

42.7% 63

14.5% 22

5.6% 0

0.0% 19

20.4% 830

31.7%

64

Table 27 : Tracheostomy, by individual hospital 2014

Hospital

Tracheostomy performed

n (%)

Tracheostomy in relation to days of

ventilation mean (median)

Type of tracheostomy

Surgical n (%)

Percutaneous n (%)

AS 131 (10.6) 8.0 (7.0) 94 (71.8) 37 (28.2)

PP 196 (21.0) 7.8 (6.7) 54 (27.6) 142 (72.4)

IPH 161 (16.5) 8.3 (6.0) 85 (52.8) 76 (47.2)

KL 125 (8.7) 10.6 (8.5) 22 (17.6) 103 (82.4)

SLG 107 (10.3) 11.4 (10.9) 87 (81.3) 20 (18.7)

KLG 113 (8.5) 6.7 (5.5) 22 (19.5) 91 (80.5)

SBN 40 (9.5) 12.5 (9.5) 40 (100.0) 0 (0.0)

MLK 35 (3.9) 15.4 (13.5) 35 (100.0) 0 (0.0)

JB 207 (14.4) 7.7 (6.2) 68 (32.9) 139 (67.1)

KTN 117 (12.6) 9.1 (7.4) 107 (91.5) 10 (8.5)

KT 94 (9.9) 7.7 (6.1) 76 (80.9) 18 (19.1)

KB 38 (3.6) 14.9 (12.8) 24 (63.2) 14 (36.8)

KCH 65 (7.1) 8.4 (5.6) 63 (96.9) 2 (3.1)

KK 80 (10.5) 9.1 (7.7) 72 (90.0) 8 (10.0)

SP 46 (6.1) 12.9 (12.0) 46 (100.0) 0 (0.0)

PJY 20 (4.6) 10.2 (7.0) 20 (100.0) 0 (0.0)

MUR 23 (5.0) 10.9 (6.3) 22 (95.7) 1 (4.3)

TI 20 (6.4) 7.2 (4.9) 20 (100.0) 0 (0.0)

TPG 59 (6.5) 9.2 (6.3) 59 (100.0) 0 (0.0)

SJ 40 (11.5) 10.1 (9.5) 34 (85.0) 6 (15.0)

KJG 35 (17.0) 4.4 (4.4) 35 (100.0) 0 (0.0)

KGR 12 (4.4) 8.5 (8.5) 12 (100.0) 0 (0.0)

SJMC 0 (0.0) 0.0 (0) 0 (0.0) 0 (0.0)

TML 50 (8.0) 11.6 (8.3) 50 (100.0) 0 (0.0)

KP 12 (3.2) 14.7 (15.8) 12 (100.0) 0 (0.0)

SMJ 12 (4.0) 7.6 (5.4) 1 (8.3) 11 (91.7)

BP 48 (12.4) 7.7 (6.6) 48 (100.0) 0 (0.0)

TW 42 (11.4) 11.1 (6.0) 42 (100.0) 0 (0.0)

MRI 16 (4.7) 9.1 (8.9) 16 (100.0) 0 (0.0)

KLM 32 (6.8) 6.8 (6.1) 32 (100.0) 0 (0.0)

SDG 48 (8.8) 9.7 (7.6) 47 (97.9) 1 (2.1)

SB 73 (18.7) 9.6 (8.9) 73 (100.0) 0 (0.0)

DKS 32 (4.5) 8.0 (6.8) 28 (87.5) 4 (12.5)

SI 60 (7.1) 13.2 (11.6) 46 (76.7) 14 (23.3)

SBL 192 (13.3) 10.5 (9.8) 132 (68.8) 60 (31.2)

AMP 51 (10.4) 8.9 (8.0) 2 (3.9) 49 (96.1)

LIK 2 (2.2) 10.6 (10.6) 2 (100.0) 0 (0.0)

UMMC 93 (10.2) 12.7 (10.7) 74 (79.6) 19 (20.4)

LKW 3 (2.6) 9.0 (8.9) 3 (100.0) 0 (0.0)

BM 12 (10.6) 9.6 (9.4) 10 (83.3) 2 (16.7)

65

SLR 16 (9.6) 19.6 (15.0) 15 (93.8) 1 (6.2)

PD 8 (11.3) 9.7 (5.3) 8 (100.0) 0 (0.0)

KKR 7 (4.2) 22.1 (15.4) 7 (100.0) 0 (0.0)

SGT 5 (3.9) 6.7 (5.4) 5 (100.0) 0 (0.0)

TM 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

KEM 6 (12.0) 7.7 (8.2) 6 (100.0) 0 (0.0)

KLP 1 (2.2) 6.9 (6.9) 1 (100.0) 0 (0.0)

LAB 2 (1.7) 14.8 (14.8) 2 (100.0) 0 (0.0)

KEN 7 (7.7) 12.4 (10.5) 6 (85.7) 1 (14.3)

BIN 12 (5.7) 10.2 (8.8) 12 (100.0) 0 (0.0)

LD 12 (6.7) 7.6 (5.4) 11 (91.7) 1 (8.3)

Total 2618 (9.4) 9.5 (7.6) 1788 (68.3) 830 (31.7)

Among all invasively ventilated patients, 9.4% had tracheostomies performed. The mean time from initiation of invasive ventilation to tracheostomy was 9.5 days. KJG had the shortest interval of 4.4 days while KKR had the longest interval of 22.1 days.

Table 28 : Total number of tracheostomies and percentage of percutaneous tracheostomies, by individual hospital 2010 – 2014

Total number of tracheostomies (% percutaneous tracheostomies)

n (%)

2010 2011 2012 2013 2014

AS 105 (42.9) 126 (23.0) 150 (23.3) 160 (23.1) 131 (28.2)

PP 135 (63.0) 199 (64.8) 210 (65.7) 196 (65.8) 196 (72.4)

IPH 153 (3.9) 140 (2.9) 109 (16.5) 141 (50.4) 161 (47.2)

KL 142 (78.2) 128 (75.0) 149 (75.8) 119 (74.8) 125 (82.4)

SLG 66 (8.0) 77 (18.2) 102 (28.4) 121 (28.1) 107 (18.7)

KLG 110 (21.8) 190 (73.7) 155 (76.1) 133 (75.9) 113 (80.5)

SBN 59 (0.0) 68 (1.5) 55 (0.0) 50 (0.0) 40 (0.0)

MLK 105 (0.0) 100 (1.0) 88 (0.0) 57 (0.0) 35 (0.0)

JB 325 (77.8) 465 (79.4) 332 (73.2) 238 (68.1) 207 (67.1)

KTN 40 (5.0) 80 (7.5) 112 (4.5) 115 (7.8) 117 (8.5)

KT 60 (78.3) 67 (50.7) 88 (37.5) 95 (38.9) 94 (19.1)

KB 14 (14.3) 29 (24.1) 27 (37.0) 40 (22.5) 38 (36.8)

KCH 47 (17.0) 63 (36.5) 71 (23.9) 76 (6.6) 65 (3.1)

KK 58 (24.1) 46 (8.7) 104 (25.0) 123 (14.6) 80 (10.0)

SP 8 (0.0) 23 (0) 11 (0.0) 30 (0.0) 46 (0.0)

PJY 11 (0.0) 21 (0) 26 (0.0) 19 (5.3) 20 (0.0)

MUR 26 (3.8) 36 (0) 40 (2.5) 29 (0.0) 23 (4.3)

TI 8 (0.0) 18 (0) 24 (0.0) 13 (0.0) 20 (0.0)

TPG 145 (0.7) 149 (0) 127 (0.8) 108 (0.0) 59 (0.0)

66

SJ 60 (8.3) 61 (37.7) 57 ( 22.8) 42 (69.0) 40 (15.0)

KJG 26 (0.0) 19 (5.3) 14 (0.0) 24 (0.0) 35 (0.0)

KGR 11 (0.0) 7 (0) 19 (0.0) 38 (2.6) 12 (0.0)

SJMC 2 (0.0) 6 (16.7) 3 (33.3) 3 (0.0) 0 (0.0)

TML 45 (0.0) 38 (0) 29 (3.4) 39 (0.0) 50 (0.0)

KP 7 (0.0) 27 (0) 24 (0.0) 14 (0.0) 12 (0.0)

SMJ 9 (66.7) 9 (88.9) 16 (75.0) 10 (100.0) 12 (91.7)

BP 46 (0.0) 54 (0) 36 (0.0) 35 (0.0) 48 (0.0)

TW 10 (0.0) 21 (0) 25 (0.0) 34 (2.9) 42 (0.0)

MRI 10 (20.0) 8 (0) 33 (18.2) 22 (4.5) 16 (0.0)

KLM 47 (0.0) 55 (0) 78 (0.0) 46 (0.0) 32 (0.0)

SDG 44 (43.2) 52 (42.3) 56 (32.1) 64 (7.8) 48 (2.1)

SB 22 (18.2) 36 (0) 56 (3.6) 52 (0.0) 73 (0.0)

DKS 13 (53.8) 21 (76.2) 25 (80.0) 36 (88.9) 32 (12.5)

SI 30 (26.7) 64 (26.6) 66 (24.2) 72 (9.7) 60 (23.3)

SBL 212 (87.3) 262 (68.3) 206 (42.7) 197 (42.6) 192 (31.2)

AMP 33 (97.0) 55 (92.7) 59 (93.2) 55 (85.5) 51 (96.1)

LIK 0 (0.0) 1 (0) 5 (0.0) 6 (0.0) 2 (0.0)

UMMC 76 (21.1) 64 (18.8) 93 (20.4)

LKW 10 (0.0) 11 (0.0) 3 (0.0)

BM 11 (0.0) 17 (17.6) 12 (16.7)

SLR 5 (0.0) 7 (14.3) 16 (6.2)

PD 5 (0.0) 5 (0.0) 8 (0.0)

KKR 6 (0.0) 7 (0.0) 7 (0.0)

SGT 7 (0.0) 10 (0.0) 5 (0.0)

TM - 0 (0.0)

KEM 1 (0.0) 1 (0.0) 6 (0.0)

KLP - 1 (0.0) 1 (0.0)

LAB 6 (0.0) 14 (0.0) 2 (0.0)

KEN - 9 (0.0) 7 (14.3)

BIN 12 (58.3) 12 (0.0) 12 (0.0)

LD 10 (80.0) 21 (23.8) 12 (8.3)

Total 2244 (39.0) 2821 (41.7) 2936 (35.8) 2831 (33.2) 2618 (31.7)

In 2014, 31.7% of all tracheostomies were performed percutaneously. The percentage of percutaneous tracheostomies had increased from 2002 until 2011. This however, decreased in trend since 2012.

67

Table 29 : Withdrawal / Withholding therapy, by individual hospital 2010 – 2014

Hospital

Withdrawal / Withholding of therapy n (%)

2010 2011 2012 2013 2014

AS 181 (54.4) 192 (66.2) 203 (64.2) 253 (71.5) 317 (84.3)

PP 44 (41.9) 105 (60.7) 191 (91.4) 133 (78.2) 85 (42.7)

IPH 0 (0.0) 0 (0.0) 7 (4.6) 48 (23.1) 39 (19.8)

KL 183 (60.6) 230 (73.5) 299 (83.8) 267 (80.4) 250 (81.4)

SLG 3 (1.6) 6 (2.9) 42 (20.9) 110 (54.7) 71 (37.0)

KLG 25 (11.2) 162 (58.9) 206 (63.2) 137 (49.5) 164 (54.1)

SBN 47 (44.8) 58 (49.2) 61 (52.6) 36 (38.7) 48 (42.9)

MLK 41 (11.5) 38 (10.4) 22 (5.7) 58 (15.4) 146 (52.5)

JB 196 (71.5) 270 (72.8) 278 (75.7) 332 (79.8) 234 (83.0)

KTN 16 (11.5) 4 (3.8) 9 (5.8) 11 (6.0) 12 (6.4)

KT 102 (46.2) 82 (32.5) 54 (21.5) 48 (19.2) 23 (9.5)

KB 24 (15.1) 3 (1.5) 48 (23.8) 33 (17.5) 23 (12.7)

KCH 19 (23.5) 1 (0.7) 8 (5.4) 7 (4.2) 18 (11.2)

KK 27 (14.6) 29 (17.9) 43 (22.8) 60 (30.9) 121 (72.5)

SP 14 (21.9) 1 (1.1) 0 (0.0) 5 (3.9) 21 (10.0)

PJY 1 (1.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

MUR 4 ( 3.1) 4 ( 3.1) 33 (22.4) 38 (29.0) 43 (30.7)

TI 6 (10.3) 0 (0.0) 1 (1.5) 3 (3.7) 2 (2.2)

TPG 79 (25.8) 56 (24.1) 108 (43.2) 100 (43.1) 105 (46.3)

SJ 68 (58.1) 53 (36.3) 67 (48.9) 40 (37.0) 13 (14.3)

KJG 2 ( 4.7) 5 ( 8.6) 4 (7.7) 1 (2.0) 0 (0.0)

KGR 60 (95.2) * 1 (1.8) 0 (0.0) 11 (19.3)

SJMC 0 (0.0) 2 (2.3) 4 (6.5) 0 (0.0) 0 (0.0)

TML 8 ( 5.3) 2 ( 1.9) 4 (6.3) 9 (9.6) 11 (7.1)

KP 19 (19.4) 21 (17.2) 19 (20.2) 43 (39.8) 41 (28.5)

SMJ 42 (50.0) 31 (33.3) 27 (28.7) 17 (17.2) 21 (18.4)

BP 10 (13.0) 13 (13.4) 11 (9.2) 28 (26.9) 11(12.0)

TW 2 (4.2) 7 (16.3) 8 (14.8) 4 (6.0) 0 (0.0)

MRI 0 (0.0) 2 (2.3) 9 (10.6) 7 (7.8) 7 (10.8)

KLM 69 (53.1) 59 (44.4) 66 (54.5) 70 (52.6) 53 (40.8)

SDG 127 (89.4) 53 (34.0) 0 (0.0) 3 (1.9) 1 (0.7)

SB 57 (51.8) 63 (46.3) 58 (54.2) 51 (42.1) 31 (26.7)

DKS 3 (2.7) 10 (7.1) 5 (3.9) 4 (1.7) 23 (12.6)

SI 1 (0.7) 21 (15.2) 11 (5.6) 11 (5.5) 9 (4.1)

SBL 82 (42.9) 185 (83.3) 198 (74.2) 212 (63.9) 262 (63.0)

AMP 29 (14.7) 8 (4.2) 146 (69.2) 46 (26.7) 21 (9.4)

LIK 0 (0.0) 1 (9.1) 0 (0.0) 3 (14.3) 0 (0.0)

UMMC - - 63 (66.3) 89 (62.7) 156 (67.0)

LKW - - 11 (25.0) 8 (25.8) 3 (7.5)

BM - - 0 (0.0) 0 (0.0) 0 (0.0)

68

SLR - - 2 (3.4) 0 (0.0) 4 (5.8)

PD - - 7 (26.9) 19 (50.0) 1 (2.6)

KKR - - 8 (38.1) 24 (42.9) 5 (9.1)

SGT - - 1 (3.8) 3 (10.0) 4 (14.8)

TM - - 0 (0.0) 1 (3.7) 19 (55.9)

KEM - - 3 (33.3) 6 (40.0) 4 (33.3)

KLP - - - 1 (10.0) 1 (9.1)

LAB - - 5 (16.7) 0 (0.0) 1 (1.50

KEN - - 0 (0.0) 1 (9.1) 0 (0.0)

BIN - - 6 (16.7) 6 (18.2) 0 (0.0)

LD - - 2 (4.2) 2 (4.3) 7 (13.0)

Total 1591 (29.6) 1778 (30.8) 2359 (36.9) 2388 (35.1) 2442 (35.2) Withdrawal or withholding of therapy : refers to the discontinuation/not initiating any of the following: vasoactive drugs, renal replacement therapy, mechanical ventilation, surgery, cardiopulmonary resuscitation

Therapy was withheld or withdrawn in 35% of deaths in ICU. There was a wide variability of this practice ranging from 0% (BM, SJMC, LIK, PJY, KEN, BIN, TW, KJG) to 84% (AS). In a retrospective audit of all deaths in two major tertiary ICUs in New South Wales, Australia in 2008, 34% had treatments withheld and another 47% had withdrawal of life-sustaining therapy [10].

In a prospective observational study of the end-of-life practices in 37 ICUs in 17 European countries from January 1, 1999, to June 30, 2000, 72.6% of those who died had life-limiting treatment [11].

69

SECTION D:

COMPLICATIONS

70

Table 30 : Incidence of ventilator-associated pneumonia, by individual hospital 2009 – 2014

Hospital VAP per 1000 ventilator days

2009 2010 2011 2012 2013 2014

AS 4.4 9.6 7.5 3.0 1.3 0.6

PP 10.8 12.9 10.1 6.9 4.2 4.4

IPH 22.1 12.3 3.7 7.2 8.8 4.4

KL 12.3 15.2 13.6 13.5 7.5 6.0

SLG 21.4 13.5 8.4 4.6 5.6 3.8

KLG 4.4 3.5 3.8 3.6 9.2 3.1

SBN 7.3 8.7 4.4 2.4 3.4 2.5

MLK 2.8 8.5 9.1 7.0 1.6 0.9

JB 5.5 9.0 5.4 4.3 0.9 0.5

KTN 3.4 3.3 1.6 2.7 1.2 0.4

KT 1.6 8.7 4.1 7.2 2.9 0.8

KB 3.4 4.1 5.6 9.2 7.5 4.2

KCH 10.7 5.0 2.4 6.3 0.0 2.1

KK - 0.4 - 0.8 2.4 3.2

SP 39.5 23.4 23.6 8.3 4.3 7.2

PJY 18.3 14.4 9.3 3.8 8.6 2.6

MUR 7.1 4.9 1.7 0.6 0.7 0.6

TI 5.4 8.8 1.4 2.0 0.0 4.1

TPG 28.8 3.0 0.6 1.1 0.0 0.2

SJ 28.4 14.7 5.4 3.5 3.3 5.6

KJG 15.7 10.9 6.0 10.3 14.3 4.8

KGR 6.0 10.8 8.7 21.0 11.8 8.6

TML 2.6 4.0 0.5 0 1.6 4.2

KP 4.1 2.2 0.7 0.8 1.9 2.9

SMJ 28.7 37.3 3.2 2.9 0.0 1.2

BP 1.6 2.3 0.7 1.7 0.6 0.6

TW 3.2 8.7 4.3 8.3 8.9 5.4

MRI 10.5 2.8 1.8 3.2 3.5 8.4

KLM 18.8 36.7 24.7 28.3 8.6 10.3

SDG 21.7 13.5 13.4 9.3 7.7 2.8

SB - 7.7 10.4 11.3 6.2 7.7

DKS - 7.0 0.4 1.6 0.0 2.2

SI - 11.1 12.5 16.6 8.3 5.0

SBL - 22.7 9.9 7.1 7.6 4.2

AMP - 18.4 33.0 35.0 14.5 6.6

LIK - 0.0 0.0 4.1 0.0 1.6

LKW - - - 16.2 0.0 0.0

BM - - - - 0.7 0.8

SLR - - - 24.9 13.3 11.2

PD - - - 17.5 3.0 3.1

KKR - - - 9.5 22.2 18.0

SGT - - - 16.8 5.1 6.5

TM - - - - 0.0 0.0

KEM - - - - 0.0 0.0

71

KLP - - - - 0.0 0.0

LAB - - - 3.6 2.0 11.1

KEN - - - - 2.3 0.0

BIN - - - 22.4 11.2 0.3

LD - - - 3.2 1.0

MOH hospitals 11.6 10.1 6.8 7.2 5.4 3.6

SJMC 0.0 3.4 8.0 0 8.4 -

UMMC 8.5 6.0 7.3

VAP: Defined as nosocomial pneumonia developing in a patient after 48 hours of mechanical ventilation with radiological evidence of new or progressive infiltrates with or without the presence of a positive bacteriological culture

Table 31 : Onset of VAP from initiation of invasive ventilation,

by individual hospital 2010 – 2014

Hospital

Interval from initiation of ventilation to VAP Mean (Median) days

2010 2011 2012 2013 2014

AS 7.6 7.9 11.0 (9.0) 19.6 (15.0) 11.9 (10.3)

PP 10.0 11.0 11.2 (7.8) 14.0 (13.2) 16.9 (15.8)

IPH 4.3 7.7 9.1 (7.7) 7.1 (5.7) 7.7 ( 7.1)

KL 11.2 11.8 10.3 (8.9) 13.3 (11.0) 13.6 (12.1)

SLG 11.9 11.2 11.4 (8.0) 12.0 (11.5) 13.3 (11.7)

KLG 14.0 11.0 12.9 (12.0) 7.3 (5.8) 12.0 (11.6)

SBN 10.1 15.4 7.7 (8.3) 15.2 (7.3) 9.0 (7.1)

MLK 7.8 7.2 7.8 (5.5) 20.0 (8.6) 30.3 (31.0)

JB 8.8 8.4 10.5 (5.7) 9.3 (6.5) 7.6 (5.6)

KTN 7.0 9.5 11.5 (10.9) 11.8 (6.6) 20.4 (20.4)

KT 7.2 8.6 10.9 (10.0) 11.7 (11.2) 15.3 (15.3)

KB 9.1 11.9 13.6 (11.3) 12.0 (10.7) 16.7 (16.4)

KCH 11.5 11.4 9.3 (6.6) 12.6 (12.1) 6.4 (7.6)

KK 11.2 * 7.7 (7.1) 10.0 (7.3) 13.4 (8.9)

SP 7.2 7.0 6.5 (6.5) 9.6 (7.9) 8.0 (6.6)

PJY 9.9 13.9 12.3 (10.9) 8.1 (7.7) 12.7 (8.6)

MUR 10.3 12.2 - - 13.3 (13.3)

TI 25.0 19.5 16.8 (16.8) 12.2 (12.2) 9.6 (10.4)

TPG 7.9 9.6 16.3 (13.1) - -

SJ 6.5 9.3 12.0 (10.3) 14.6 (7.9) 9.5 (10.0)

KJG 6.4 6.2 7.6 (6.7) 7.9 (6.6) 6.4 (5.8)

KGR 7.2 3.9 9.6 (7.2) 9.1 (7.4) 8.5 (6.3)

SJMC 2.0 5.4 - 3.9 (3.9) -

TML 10.3 9.0 - 6.8 (6.8) 10.2 (8.3)

KP 6.5 20.3 21.3 (21.3) 5.1 (5.1) 15.2 (15.2)

SMJ 5.7 13.2 12.6 (12.6) 3.7 (3.7) 7.4 (7.4)

BP 21.5 7.1 32.0 (32.0) 10.1 (10.1) 8.2 (8.2)

TW 6.1 10.1 5.6 (4.1) 5.7 (4.2) 11.8 (10.5)

MRI 8.9 4.0 6.8 (6.8) 12.9 (7.5) 8.0 (8.0)

KLM 5.9 7.6 6.4 (4.6) 7.6 (8.0) 8.0 (6.1)

SDG 6.6 7.9 12.4 (12.1) 9.6 (8.2) 13.3 (10.8)

SB 7.8 6.0 10.6 (7.2) 9.1 (8.6) 8.4 (7.6)

DKS 7.7 7.1 7.0 (5.5) 6.6 (5.6) 6.4 (6.4)

72

SI 12.8 12.1 11.5 (10.0) 9.7 (7.5) 10.3 (9.1)

SBL 9.1 10.7 9.6 (7.8) 7.9 (6.3) 9.5 (9.2)

AMP 7.1 8.5 6.5 (5.3) 8.6 (7.9) 7.6 (7.1)

LIK - - 3.0 (3.0) - 20.7 (20.7)

UMMC - - 15.2 (10.8) 8.2 (7.8) 11.2 (8.0)

LKW - - 6.0 (4.4) 9.4 (3.9) -

BM - - 2.2 (2.2) - 6.2 (6.2)

SLR - - 8.5 (5.9) 10.0 (7.8) 11.5 (10.3)

PD - - 9.5 (9.5) 11.5 (11.5) -

KKR - - 8.8 (9.5) 13.3 (9.4) 7.4 (6.9)

SGT - - 10.0 (7.3) 6.3 (6.3) 7.0 (8.2)

TM - - - 6.4 (6.5) -

KEM - - - - -

KLP - - - - -

LAB - - 10.1 (10.1) 15.9 (15.9) 9.3 (9.3)

KEN - - - - 2.5 (2.5)

BIN - - 12.2 (11.2) 8.5 (9.2) 8.2 (8.2)

LD - - 10.5 (10.5) 7.6 (5.6) 6.3 (6.3)

Total 8.8 9.7 10.1 (7.8) 10.0 (7.9) 10.8 (8.8)

Figure 21 : Ventilator-associated pneumonia, per 1000 ventilator days 2004 – 2014

15.4

11.610.1

6.8 7.2

5.4

3.6

14.9

23.1

13.5

0

5

10

15

20

25

2004 2005 2007 2008 2009 2010 2011 2012 2013 2014Year

VA

P p

er 1

000

ven

tila

tor

day

s

....

.

73

Figure 22 : Ventilator-associated pneumonia, per 1000 ventilator days, by individual hospital 2014

0 2 4 6 8 10 12 14 16 18 20

SBLKLG

KLJB

KBMLKSLGUMAS

IPHTPG

KTKCH

PPSI

KTNKKSP

DKSSJM

TMLSDGPJY

AMPMURKLMSBN

KPTWBP

SMJSB

MRISJTI

LIKKGRKJGBINPD

KKRSLRLD

LABLKW

TMSGT

KENBM

KLPKEM

VAP per 1000 ventilator days

74

National Healthcare Safety Network (NHSN) report, data summary for 2012 [12]

Types of ICU

Ventilator utilisation ratio

VAP per 1000 ventilator days

Pooled mean

Percentile

10th 25th 50th 75th 90th

Mixed medical/ surgical > 15 beds

0.34

0.9

0.0

0.0

0.4

1.3

2.8

Mixed medical/ surgical < 15 beds

0.24

1.1

0.0

0.0

0.0

1.2

3.6

Neurosurgical 0.30 2.1 0.0 0.0 1.5 2.9 3.8

Surgical 0.34 2.0 0.0 0.0 0.9 2.8 5.9

Trauma 0.47 3.6 0.0 0.8 2.6 6.0 9.4

The incidence of VAP had decreased steadily over the past 8 years. In 2007, the VAP rate was 15.4 per 1000 ventilator days. It had decreased by more than half to 5.4 per 1000 ventilator days in 2013 and 3.6 per 1000 ventilator days in 2014. The mean rate of VAP (3.6 per 1000 ventilator days) in our ICUs was much higher when benchmarked with that of US National Healthcare Safety Network (NHSN) [12]; as shown in the table above. The definition for VAP by NHSN has a more stringent inclusion criterion (resulting in fewer cases being defined as VAP) compared to ours. However, the rate of VAP in our ICUs was lower compared with the pooled VAP rate of 15.8 per 1000 ventilator days as reported by Rosenthal et. al.[13] in ICUs in 36 countries in Latin America, Asia, Africa and Europe between 2004 to 2009. Ventilator usage is a significant risk factor for developing VAP and the exposure to this risk is measured by ventilator utilisation ratio, which is calculated by dividing the number of ventilator days to number of patient days. Ventilator utilisation ratio in our ICUs was 0.6, which is more than two times higher than the ICUs in US.

The onset of VAP was 10.8 days from the initiation of invasive ventilation. Onset of VAP in all centres (except KEN) exceeded 5 days of ventilation, indicating that VAPs in MOH and UMMC ICUs were mostly of late onset.

75

Table 32 : Bacteriological cultures in VAP, by category of ICU 2014

Organisms ICUs

Adm ≥ 1000 n (%)

Adm 500 - 999 n (%)

Adm < 500 n (%)

UMMC n (%)

Total n (%)

Acinetobacter spp.

MRO

Non-MRO

110 (37.0 )

104 (94.5)

6 (5.5)

46 (52.9 )

43 (93.5)

3 (6.5)

38 (44.2 )

31 (81.6)

7 (18.4)

21 (58.3 )

16 (76.2)

5 (23.8)

215 (42.5)

194 (90.2)

21 (9.8)

Pseudomonas aeruoginosa MRO

Non-MRO

69 (23.2 )

21 (30.4)

48 (69.6)

10 (11.5 )

2 (20.0)

8 (80.0)

13 (15.1 )

6 (46.2)

7 (53.8)

9 (25.0)

0 (0.0)

9 (100.0)

101 (20.0 )

29 (28.7)

72 (71.3)

Klebsiella spp.

ESBL

Non-ESBL

67 (22.6 )

49 (73.1)

18 (26.9)

17 (19.5 )

14 (82.4)

3 (17.6)

21 (24.4 )

14 (66.7)

7 (33.3)

5 (13.9 )

2 (40.0)

3 (60.0)

110 (21.7 )

79 (71.8)

31 (28.2)

MRSA 9 (3.0 ) 1 (1.1 ) 1 (1.2 ) 1 (2.8 ) 12 (2.4 )

MSSA 7 (2.4 ) 4 (4.6 ) 3 (3.5 ) 0 (0) 14 (2.8 )

Stenotrophomonas

maltophilia

8 (2.7 ) 0 (0) 0 (0) 0 (0) 8 (1.6 )

Coagulase negative

Staphylococcus

2 (0.7 ) 1 (1.1 ) 1 (1.2 ) 0 (0) 4 (0.8 )

Other gram negative

bacteria

4 (1.3 ) 1 (1.1) 0 (0) 0 (0) 5 (1.0 )

Fungal 6 (2.0 ) 1 (1.1 ) 2 (2.3 ) 0 (0) 9 (1.8 )

Others 15 (5.1 ) 6 (6.9 ) 7 (8.1 ) 0 (0) 28 (5.5 )

Total 297 (100.0) 87 (100.0) 86 (100.0) 36 (100.0) 506 (100.0)

MRSA : Methicillin-resistant Staphylococcus aureus MSSA : Methicillin-sensitive Staphylococcus aureus

Figure 23 : Bacteriological cultures in VAP 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Adm ≥1000 Adm 500-999 Adm <500 UMMC

Per

cen

tag

e o

f o

rgan

ism

iso

late

d...

......

......

......

.

Others

Fungal

Methicillin-resistance Staphaureus

Coagulase negativeStaphylococcus

Methicillin-sensitive Staphaureus

Other gram negative bacteria

Stenotrophomonasmaltophilia

Klebsiella spp non-ESBL

Klebsiella spp ESBL

Pseudomonas aeruginosa

Acinetobacter spp.

76

Table 33 : Bacteriological cultures in VAP 2008 – 2014

Organisms

2008 n (%)

2009 n (%)

2010 n (%)

2011 n (%)

2012 n (%)

2013 n (%)

2014 n (%)

Acinetobacter spp. 219 (27.7) 267 (39.0) 350 (44.8) 377 (48.2) 351 (44.4) 315 (45.3) 215 (42.5)

Klebsiella spp. 127 (16.0) 128 (18.7) 152 (19.5) 131 (16.7)

165

(20.8)

149

(21.4)

110 (21.7)

Pseudomonas aeruginosa

168 (21.2) 107 (15.6) 135 (17.3) 112 (14.3) 139 (17.5) 120 (17.2) 101 (20.0)

MRSA 63 (8.0) 50 (7.3) 22 (2.8) 31 (3.9) 12 (1.5) 31 (4.5) 12 (2.4)

MSSA 73 (9.2) 39 (5.7) 24 (3.1) 21 (2.6) 19 (2.4) 11 (1.6) 14 (2.8)

Stenotrophomonas maltophilia

25 (3.2) 20 (2.9) 20 (2.6) 19 (2.4) 20 (2.5) 17 (2.4) 8 (1.6)

Other gram negative bacteria

16 (2.0) 7 (1.0) 10 (1.3) 17 (2.1) 16 (2.0) 6 (0.9) 5 (1.0)

Fungi 11 (1.4) 6 (0.9) 19 (2.4) 21 (2.6) 22 (2.7) 9 (1.3) 9 (1.8)

Coagulase negative Staphylococcus

16 (2.0) - 11 (1.4) 13 (1.6) 10 (1.2) 4 (0.6) 4 (0.8)

Others 73 (9.2) 60 (8.8) 38 (4.9) 40 (5.1) 36 (4.5) 34 (4.9) 28 (5.5)

Figure 24 : Common bacteriological cultures in VAP 2008 – 2014

0

10

20

30

40

50

60

2008 2009 2010 2011 2012 2013 2014

Perc

en

tag

e o

f o

rga

nis

m i

so

late

d..

......

......

......

...

Acinetobacter spp.

Klebsiella spp.

Pseudomonasaeruginosa

MRSA

MSSA

Stenotrophomonasmaltophilia

Other gram negativebacteria

Fungi

Coagulase negativeStaphylococcus

77

For MOH ICUs in 2014, gram-negative organisms accounted for 92% of the causative organisms in VAP. Over the last 7 years, the most common organisms were Acinetobacter spp., Klebsiella spp. and Pseudomonas aeruginosa. Acinetobacter spp. have been the leading causative organism in VAP since 2007, accounting for 42.5% of all organisms in 2014. Fifty eight percent of the causative organisms in VAP in MOH ICUs were of multi-drug resistant strains. Acinetobacter spp, Klebsiella spp and Pseudomonas aeuroginosa constituted 60.3%, 26.1% and 9.8% of multi-drug resistant strains respectively. Methicillin-resistant Staphyloccus aureus accounted for 46.2% of all Staphyloccus aureus isolated. In UMMC, gram-negative organisms accounted for 97.2% of all causative organisms in VAP. Fifty-three percent of the causative organisms were of multi-drug resistant strains. In the INICC report [12], 66.3% of Acinetobacter spp isolates in patients with VAP were carbapenem-resistant , 68.9% of Klebsiella pneumonia isolates were cephalosporin-resistant and 73.2% of Staphyloccus aureus isolates were methicillin-resistant. Table 34 : Extra length of mechanical ventilation, ICU stay and Crude in-hospital

mortality in patients with VAP 2013-2014

2013 2014

Extra length of mechanical ventilation

15.1 days, RR 1.12

(95% CI 1.11-1.13)

13.5 days, RR 1.09

(95% CI 1.09-1.10)

Extra length of ICU stay

18.3 days, RR 1.11

(95% CI 1.10-1.12)

16.4 days, RR 1.08

(95% CI 1.07-1.09)

Extra crude mortality 26%, RR 1.54

(95% CI 1.43-1.68)

13.9% days, RR 1.79

(95% CI 1.47-2.10)

Patients with VAP stay longer on the ventilator for an additional 13 days in 2014. Their ICU stay was prolonged by an average of 16 days. They also had an excess mortality of 14%.

78

Table 35 : Unplanned extubation per 100 intubated days, by individual hospital 2010– 2014

Hospital

Unplanned extubation per 100 intubated days

2010 2011 2012 2013 2014

AS 0.4 0.3 0.3 0.3 0.2

PP 0.3 0.2 0.3 0.1 0.2

IPH 0.4 0.4 0.3 0.3 0.4

KL 1.4 1.0 0.6 0.7 0.8

SLG 0.8 0.6 0.3 0.4 0.5

KLG 0.3 0.2 0.1 0.3 0.1

SBN 0.6 0.8 0.5 0.8 1.2

MLK 0.5 0.8 0.5 0.3 0.3

JB 0.9 1.2 0.7 0.9 1.0

KTN 0.6 0.1 0.0 0.2 0.0

KT 0.6 0.6 0.3 0.1 0.3

KB 0.2 0.1 0.1 0.0 0.0

KCH 0.2 0.1 0.1 0.0 0.1

KK 0.2 0.2 0.1 0.1 0.0

SP 0.4 0.5 0.0 0.5 0.6

PJY 0.5 0.1 0.2 0.1 0.0

MUR 0.2 0.0 0.0 0.1 0.0

TI 0.9 0.2 0.0 0.0 0.0

TPG 0.4 0.5 0.3 0.3 0.0

SJ 0.5 0.4 0.2 0.5 0.1

KJG 0.7 0.0 0.0 0.8 0.4

KGR 0.3 0.0 0.1 0.0 0.1

TML 0.4 0.2 0.5 0.3 0.4

KP 0.6 0.3 0.3 0.2 0.1

SMJ 0.2 0.0 0.0 0.3 0.0

BP 0.2 0.1 0.2 0.1 0.1

TW 0.2 0.0 0.5 0.3 0.1

MRI 0.3 0.1 0.0 0.1 0.0

KLM 1.0 0.6 0.6 0.3 0.5

SDG 0.3 0.4 0.4 0.2 0.5

SB 0.3 0.1 0.0 0.2 0.0

DKS 0.2 0.0 0.0 0.3 0.6

SI 0.5 0.4 0.7 0.8 1.2

SBL 0.2 0.0 0.0 0.1 0.2

AMP 0.7 1.0 0.9 1.0 1.1

LIK 0.0 0.0 0.3 0.0 0.0

LKW 0.8 0.6 0.2

BM 0.0 0.0 0.0

SLR 0.1 0.0 0.2

79

PD 0.0 0.7 0.0

KKR 0.0 0.4 0.2

SGT 0.2 0.3 0.0

TM 0.0 0.0 0.0

KEM 0.0 0.0 0.0

KLP 0.0 1.9 0.0

LAB 0.0 0.5 0.0

KEN 0.0 0.2 0.8

BIN 0.2 0.5 0.6

LD 0.1 0.1 0.1

Total MOH 0.3 0.4

SJMC 0.3 0.2 0.0 0.0 0.0

UMMC 0.8 0.9 1.2

Total 0.5 0.4 0.3 0.3 0.4

80

Figure 25 : Unplanned extubation, by individual hospital 2014

0 0.2 0.4 0.6 0.8 1 1.2 1.4

IPHAMP

ASBINBMBP

DKSJB

KBKCHKEMKENKGRKJGKK

KKRKL

KLGKLMKLP

KPKT

KTNLAB

LDLIK

LKWMLKMRI

MURPDPJYPPSB

SBLSBNSDGSGT

SISJ

SJMCSLGSLRSMJ

SPTI

TMTMLTPGTW

UMMC

Unplanned extubation per 100 intubated days

The rate of unplanned extubation has remained fairly similar over the past 5 years with a rate of 0.4 per 100 intubated days in 2014.

81

Table 36 : Pressure ulcer, by individual hospital 2010 – 2014 Hospital Pressure ulcer per 1000 ICU days

2010 2011 2012 2013 2014

AS 14.9 15.2 8.6 10.4 4.5

PP 6.6 3.4 6.0 8.4 3.3

IPH 9.0 6.4 8.0 5.2 4.4

KL 8.3 7.9 7.1 9.7 7.3

SLG 13.5 14.4 11.3 16.6 17.8

KLG 2.4 5.6 6.1 6.5 2.3

SBN 2.6 1.1 2.8 4.2 1.9

MLK 4.5 3.8 2.5 1.3 1.9

JB 8.2 6.9 6.7 6.9 13.1

KTN 1.8 0.8 4.2 8.4 10.0

KT 4.3 2.5 1.8 1.3 0.0

KB 3.0 3.2 3.4 1.5 3.0

KCH 10.9 5.0 5.1 7.8 5.6

KK 5.2 5.1 9.8 5.8 5.3

SP 3.2 2.7 3.2 2.2 6.6

PJY 2.2 1.7 4.2 3.2 0.8

MUR 0.4 1.3 0.9 0.5 0.9

TI 3.5 1.6 1.3 0.8 0.8

TPG 9.7 5.4 1.6 1.3 0.7

SJ 9.1 3.2 2.8 10.1 5.3

KJG 10.6 14.5 5.9 2.0 5.2

KGR 4.1 2.9 13.4 14.1 13.3

TML 1.0 0.7 2.4 1.0 1.5

KP 6.1 5.7 11.2 3.7 4.9

SMJ 0.0 0.0 0.0 2.2 0.0

BP 14.7 10.1 3.9 1.9 1.5

TW 4.1 11.2 15.9 21.1 8.5

MRI 2.5 12.2 5.7 12.5 23.2

KLM 8.1 11.0 13.0 7.7 9.8

SDG 8.7 4.5 3.0 6.2 5.5

SB 9.2 9.3 10.0 17.8 13.3

DKS 7.2 0.0 2.1 6.7 2.8

SI 8.1 9.7 13.5 10.7 16.3

SBL 5.6 2.2 8.4 8.7 18.4

AMP 6.0 7.2 7.4 8.5 2.5

LIK 0.0 1.0 5.8 1.7 2.7

LKW - - 15.0 1.4 4.9

BM - - 3.7 4.2 4.9

SLR - - 2.7 2.8 11.8

PD - - 9.8 2.8 0.0

KKR - - 6.5 3.7 3.3

SGT - - 8.5 3.8 0.0

82

TM - - 0.0 4.1 1.5

KEM - - 2.5 2.0 15.4

KLP - - 0.0 11.8 3.5

LAB - - 10.4 9.7 5.9

KEN - - 0.0 4.5 9.0

BIN - - 1.9 5.0 0.0

LD - - 4.5 3.4 5.4

Total MOH 6.5 6.9

UMMC - - 27.0 7.5 5.3

SJMC 4.3 6.8 6.9 2.0 5.0

Total 6.6 5.8 6.8 6.6 6.8

Pressure ulcer: A circumscribed area in which cutaneous tissue has been destroyed and there is progressive destruction of underlying tissue caused by interference with circulation and nutrition to the area. Signs include blisters or broken skin or sore formation over pressure areas

The incidence of pressure ulcers ranged from 0.0 to 23.2 per 1000 ICU days with a mean of 6.8. For MOH hospitals, the average incidence of pressure ulcers was 6.8 per 1000 ICU days. Comparisons of rate of pressure ulcers with international standards to describe performance of individual units are not without limitations. Incidence or prevalence rates are frequently used to describe the frequency of pressure ulcers. Prevalence is a measure of the number of cases of pressure ulcers at a specific time, providing a description of the total burden of the disease, while incidence describes the number of new pressure ulcers. Incidence density describes number of new pressure ulcers per 1,000 days rather than per patient. Also the definition of pressure ulcers does vary between studies; some consider all pressure ulcers while others only include stage 2 and above ulcers. Interventions used in ICUs are sometimes contradictory to good skin care practices. For prevention of ventilator-associated pneumonia, it is recommended that the head of bed is raised to 450. However, maintaining the head of a bed that high predisposes the patient to sliding down the bed, causing shearing and friction, and leading to development of pressure ulcers. As a compromise, it is now recommended to nurse critically ill patients with head of bed elevated at 300. Hypotension predisposes to skin breakdown, yet haemodynamic instability prevents the staff from turning patients at the recommended frequency of every 2 hours.

83

Figure 26 : Pressure ulcers, by individual hospital 2014

00000

0.70.80.80.9

1.51.5

1.91.9

2.32.52.72.82.83

3.33.33.5

4.44.5

4.94.94.955.25.35.35.35.45.55.6

5.96.6

7.38.5

99.810

11.813.113.313.3

15.416.3

17.818.4

23.2

0 5 10 15 20 25

KT

SMJ

BIN

PD

SGT

TPG

PJY

TI

MUR

TML

BP

MLK

SBN

KLG

AMP

LIK

DKS

TM

KB

PP

KKR

KLP

IPH

AS

KP

LKW

BM

SJMC

KJG

UMMC

KK

SJ

LD

SDG

KCH

LAB

SP

KL

TW

KEN

KLM

KTN

SLR

JB

SB

KGR

KEM

SI

SLG

SBL

MRI

Pressure ulcer per 1000 ICU days

84

SECTION E:

MORTALITY OUTCOMES

85

Crude mortality rates are convenient measures of outcome. However, they are poor indicators of performance of intensive care as they do not take into account variations in patient characteristics such as case mix and the severity of illness.

A better measure of ICU performance is standardised mortality ratio (SMR), comparing the observed to the predicted mortality, using a severity scoring system. SMR stratifies patients according to the severity of illness. SMR of more than one indicates that the actual number of deaths is more than the predicted number of deaths and vice versa.

When interpreting SMR values, one must take into consideration factors which affect the severity scoring system used to predict mortality. These include interval between onset of illness to ICU admission (lead time bias), post-ICU care and small sample size. Lead-time bias refers to the erroneous estimation of risk at the time of admission to the ICU due to the results of therapeutic actions taken previously. Table 37 : ICU outcome, by category of ICU 2014

ICU outcome

ICUs

Adm > 1000 n (%)

Adm 500 - 999 n (%)

Adm < 500 n (%)

Private n (%)

UMMC n (%)

Total n (%)

Alive 18177 81.8%

6113 75.9%

4973 77.7%

859 98.7%

1094 81.4%

31216 80.2%

Died 3763 16.9%

1706 21.2%

1217 19.0%

11 1.3%

233 17.3%

6930 17.8%

Discharged with grave prognosis

127 0.6%

84 1.0%

77 1.2%

0 0.0%

14 1.0%

302 0.8%

Transfer to another hospital

163 0.7%

155 1.9%

135 2.1%

0 0.0%

3 0.2%

456 1.2%

Total 22230 100%

8058 100%

6402 100%

870 100%

1344 100%

38904 100%

Table 38 : Hospital outcome, by category of ICU 2014

Hospital outcome

ICUs

Adm > 1000 n (%)

Adm 500 - 999 n (%)

Adm < 500 n (%)

Private n (%)

UMMC n (%)

Total n (%)

Alive 16004 72.0%

5353 66.4%

4498 70.3%

850 97.7%

993 73.9%

27698 71.2%

Died 5178 23.3%

2219 27.5%

1556 24.3%

17 2.0%

318 23.7%

9288 23.9%

Discharged with grave prognosis

245 1.1%

123 1.5%

119 1.9%

2 0.2%

29 2.2%

518 1.3%

Transfer to another hospital

803 3.6%

363 4.5%

229 3.6%

1 0.1%

4 0.3%

1400 3.6%

Total 22230 100.0%

8058 100.0%

6402 100.0%

870 100.0%

1344 100.0%

38904 100.0%

86

Table 39 : Crude in-ICU and in-hospital mortality rate, by individual hospital 2010 – 2014

Hospital Crude in-ICU mortality (in-hospital mortality) %

2010 2011 2012 2013 2014

AS 32.1 (43.1) 24.1 (34.4) 26.7 (44.5) 27.3 (37.3) 28.9 (39.7)

PP 12.6 (22.8) 14.4 (23.3) 16.5 (26.9) 15.6 (25.0) 18.3 (25.7)

IPH 21.9 (27.3) 22.4 (30.0) 16.5 (25.5) 18.5 (25.6) 16.7 (24.7)

KL 15.5 (22.0) 17.0 (24.7) 18.4 (27.0) 17.5 (25.8) 14.3 (21.9)

SLG 18.0 (24.5) 17.9 (25.8) 16.5 (27.1) 17.2 (24.5) 15.7 (20.8)

KLG 18.7 (26.3) 17.1 (25.1) 15.5 (22.9) 13.6 (21.7) 13.3 (19.3)

SBN 19.9 (28.8) 21.3 (30.0) 22.1 (30.4) 19.7 (25.7) 21.1 (27.9)

MLK 23.2 (30.8) 23.6 (32.7) 13.5 (32.1) 19.9 (28.2) 20.0 (27.7)

JB 20.3 (27.7) 22.3 (31.4) 21.4 (30.0) 22.2 (29.9) 17.4 (25.5)

KTN 19.4 (28.5) 17.2 (24.3) 24.1 (34.9) 22.2 (32.2) 17.8 (25.5)

KT 21.3 (30.6) 20.9 (27.2) 18.5 (28.1) 22.0 (32.0) 21.0 (30.0)

KB 19.2 (26.8) 17.8 (24.4) 16.0 (22.6) 15.0 (21.3) 11.6 (16.1)

KCH 15.8 (21.1) 22.1 (29.1) 17.4 (24.3) 18.0 (24.0) 13.9 (17.7)

KK 24.6 (33.5) 20.5 (27.3) 21.7 (34.0) 19.5 (25.3) 17.2 (22.5)

SP 33.3 (43.0) 32.6 (42.2) 26.9 (38.4) 23.3 (32.6) 22.8 (30.4)

PJY 19.3 (23.1) 18.4 (21.9) 16.9 (19.3) 19.9 (22.9) 15.9 (19.6)

MUR 18.8 (24.6) 20.9 (29.2) 24.1 (33.8) 20.7 (24.7) 24.2 (26.2)

TI 21.7 (34.1) 22.4 (35.1) 17.7 (31.9) 21.9 (34.6) 23.4 (34.7)

TPG 38.1 (48.4) 27.0 (43.4) 21.4 (35.3) 19.3 (30.1) 20.9 (28.8)

SJ 22.4 (33.6) 25.2 (35.2) 23.2 (35.5) 29.3 (40.2) 24.2 (28.4)

KJG 16.1 (20.7) 19.6 (27.0) 15.0 (23.8) 15.9 (26.8) 12.0 (21.1)

KGR 21.8 (29.6) 18.1 (25.8) 16.3 (22.1) 18.0 (24.5) 17.0 (17.3)

TML 25.6 (32.5) 19.7 (23.0) 14.7 (21.0) 16.0 (22.5) 19.1 (25.7)

KP 41.9 (46.2) 34.3 (47.1) 28.9 (42.4) 28.7 (38.0) `30.5 (37.1)

SMJ 29.9(39.2) 24.5 (33.2) 24.3 (29.6) 27.6 (32.7) 30.1 (36.1)

BP 18.8 (33.0) 21.4 (32.6) 29.8 (40.7) 22.7 (31.0) 20.0 (34.6)

TW 21.8 (30.3) 15.7 (27.0) 13.7 (24.3) 17.8 (29.6) 16.3 (23.7)

MRI 15.9 (24.2) 22.6 (29.6) 18.3 (24.1) 18.7 (22.0) 15.4 (16.8)

KLM 29.7 (37.6) 30.9 (40.2) 21.0 (32.5) 25.8 (39.0) 26.5 (40.0)

SDG 17.5 (23.5) 18.0 (22.9) 17.7 (25.9) 18.3 (26.3) 16.6 (22.6)

SB 23.4 (28.9) 24.3 (31.8) 22.8 (30.2) 24.9 (39.5) 27.1 (35.3)

DKS 48.0 (59.3) 27.8 (30.2) 25.5 (26.8) 26.9 (31.3) 22.3 (31.5)

SI 26.8 (31.7) 22.1 (28.7) 24.6 (28.6) 21.2 (26.5) 20.2 (26.1)

SBL 16.0 (23.3) 18.0 (28.5) 17.2 (25.2) 18.6 (26.9) 18.7 (24.1)

AMP 37.1 (41.8) 35.1 (43.9) 37.9 (47.8) 31.1 (42.1) 35.6 (44.0)

LIK 1.9 (1.9) 2.9 (3.7) 5.6 (6.5) 4.1 (6.0) 2.3 (4.0)

LKW - - 28.6 (36.2) 17.8 (22.3) 26.1 (33.3)

BM - - 13.2 (21.1) 29.8 (34.8) 19.9 (22.2)

SLR - - 42.8 (52.6) 27.6 (31.1) 32.7 (39.0)

PD - - 14.6 (18.4) 15.9 (23.0) 15.5 (20.0)

KKR - - 15.0 (24.4) 23.7 (28.7) 21.5 (21.5)

87

SGT - - 24.5 (30.4) 21.4 (34.5) 18.0 (25.3)

TM - - 5.9 (11.8) 23.7 (24.4) 22.5 (24.4)

KEM - - 9.9 (12.6) 15.3 (17.1) 13.2 (23.1)

KLP - - 0 (0) 8.6 (11.2) 12.5 (14.6)

LAB - - 29.7 (34.3) 35.7 (40.0) 40.4 (43.4)

KEN - - 11.4 (20.0) 6.8 (12.4) 9.7 (12.5)

BIN - - 17.8 (27.7) 12.7 (17.7) 14.5 (19.8)

LD - - 29.8 (38.1) 23.0 (35.3) 29.5 (40.6)

MOH Hospitals 20.9 (28.1) 21.2 (29.5 ) 19.4 (27.9) 19.9 (27.7) 19.0 (25.7)

SJMC 4.2 (4.6) 4.3 (4.8) 4.3 (4.9) 2.4 (3.0) 1.3 (2.2)

UMMC - - 20.3 (31.8) 16.7 (24.8) 18.4 (25.8)

The overall in-ICU and in-hospital mortality rates for MOH hospitals in 2014 were 19.0% and 25.7% respectively. UMMC had fairly similar in-ICU and in-hospital mortality rates of 18.4% and 25.8% respectively. SJMC had a very low in-ICU and in-hospital mortality rates of 1.3% and 2.2% respectively.

88

Figure 27 : Crude In-ICU and In-hospital mortality rates, by individual hospital 2014

0 5 10 15 20 25 30 35 40 45 50

LABAMP

SLRKP

SMJLDASSB

KLMLKW

SJMUR

TISP

TMDKSKKRSBN

KTTPG

SIBP

MLKBM

TMLSBL

UMMCPP

SGTKTN

JBKK

KGR IPHSDGTWPJY

SLGPD

MRIBINKL

KCHKLGKEMKLPKJGKB

KENLIK

SJMC

Crude mortality rate %

In-hospital mortality

In-ICU mortality

89

Table 40 : Ten most common diagnoses leading to ICU admission in MOH hospitals and observed in-hospital mortality 2010 – 2014

Diagnosis Mortality (%)

2010 2011 2012 2013 2014

Dengue infection 8.6 6.4 5.6 5.6 7.1

Sepsis 59.3 58.9 54.4 53.4 52.8

Head injury 27.4 25.2 23.1 22.1 22.2

Community-acquired pneumonia

42.6 40.6 39.0 38.9 36.2

Cerebral vascular disease - 41.9 40.5 45.5 41.1

Chronic lower respiratory disease

26.2 24.9 23.6 22.1 18.8

Bronchial asthma 7.8 10.9 7.5 8.1 7.6

Non-cardiogenic pulmonary oedema

29.5 22.3 18.9 21.4 21.6

Infection/gangrene of limb (include osteomyelitis, necrotising fasciitis)

39.1 41.8 39.6 37.7 36.9

DKA/HHS - - - 21.1 19.3

In-hospital mortality for dengue infection increased slightly in 2014 compared to the previous years. In-hospital mortality for patients with sepsis, community-acquired pneumonia, and acute exacerbation of chronic lower respiratory disease had steadily improved over the past five years. Table 41 : Severe sepsis, ARDS and AKI within 24hrs of ICU admission and observed

in-hospital mortality 2012 - 2014

In-hospital Mortality (%)

2012 2013 2014

Severe sepsis 43.1 41.6 35.5

ARDS 37.3 36.6 35.9

AKI 41.4 43.9 38.0

Severe sepsis + ARDS 67.1 60.3 62.7

Severe sepsis + AKI 61.3 59.3 61.5

Severe sepsis + ARDS + AKI 80.4 73.4 73.7

The in-hospital mortality for severe sepsis within 24 hours of ICU admission decreased to 35.5% in 2014. However, it is higher when compared with the in-ICU mortality of the Sepsis Occurrence in Acutely Ill Patient (SOAP) study. The in-ICU mortality was 27% in patient with sepsis on ICU admission [5].

Reported mortality in ICU patients with AKI varies considerably between studies depending on definition of AKI, patient population (e.g., sepsis, trauma, cardiothoracic surgery) and severity of AKI. Patients with maximum RIFLE class R, class I and class F had hospital mortality rates of 8.8%, 11.4% and 26.3%, respectively [14]. Payen et al reported that patients with acute renal failure had higher mortality rates than patients without acute renal failure among patients enrolled in the SOAP study (60-day mortality 35.7% versus 16.4%; P < 0.01) [15].

90

Table 42 : Standardised mortality ratio, by individual hospital 2010 – 2014

Hospital

Standardised mortality ratio (95% CI)

2010 2011 2012 2013 2014

AS 0.93 0.82 (0.60-1.11) 1.07 (0.81-1.39) 1.01 (0.76-1.32) 0.91 (0.68-1.20)

PP 0.68 0.67 (0.47-0.96) 0.74 (0.51-1.01) 0.71 (0.49-0.99) 0.69 (0.49-0.98)

IPH 0.82 0.96 (0.67-1.35) 0.83 (0.58-1.17) 0.74 (0.51-1.04) 0.75 (0.52-1.05)

KL 0.62 0.61 (0.43-0.87) 0.63 (0.44-0.88) 0.60 (0.42-0.84) 0.58 (0.39-0.82)

SLG 0.76 0.75 (0.52-1.05) 0.75 (0.54-1.05) 0.68 (0.48-0.97) 0.63 (0.43-0.91)

KLG 0.85 0.62 ( 0.43-0.87) 0.60 (0.41-0.86) 0.54 (0.37-0.80) 0.57 (0.38-0.84)

SBN 0.74 0.77 (0.55-1.04) 0.73 (0.50-1.03) 0.71 (0.51-0.99) 0.79 (0.56-1.10)

MLK 0.97 0.98 (0.71-1.33) 0.81 (0.58 –1.10) 0.86 (0.61-1.21) 0.82 (0.59-1.15)

JB 0.71 0.78 (0.56-1.05) 0.71 (0.51-0.97) 0.66 (0.47-0.91) 0.61 (0.42-0.85)

KTN 0.90 0.72 (0.50-1.01) 0.84 (0.62-1.21) 0.82 (0.58-1.09) 0.69 (0.49-0.97)

KT 0.86 0.67 (0.48-0.94) 0.65 (0.46-0.89) 0.72 (0.53-0.98) 0.73 (0.54-1.00)

KB 1.00 0.76 (0.52-1.07) 0.67 (0.46-0.95) 0.62 (0.44-0.92) 0.60 (0.39-0.91)

KCH 0.63 0.82 (0.58-1.13) 0.75 (0.51-1.06) 0.69 (0.47-0.98) 0.56 (0.36-0.84)

KK 0.83 0.71 (0.50-1.00) 1.00 (0.70-1.38) 0.8 (0.55-1.14) 0.51 (0.36-0.74)

SP 0.97 1.00 (0.75-1.30) 0.77 (0.57-1.03) 0.75 (0.54-1.02) 0.79 (0.56-1.07)

PJY 0.83 0.76 (0.50-1.10) 0.69 (0.45-1.03) 0.80 (0.54-1.14) 0.59 (0.40-0.88)

MUR 0.88 0.78 (0.56-1.06) 0.89 (0.63-1.23) 0.55 (0.37-0.79) 0.63 (0.44-0.88)

TI 0.71 0.77 (0.57-1.05) 0.72 (0.53-0.99) 0.65 (0.46-0.88) 0.74 (0.53-1.00)

TPG 1.03 0.92 (0.69-1.20) 0.80 (0.58-1.07) 0.64 (0.45-0.89) 0.68 (0.49-0.95)

SJ 0.76 0.84 (0.61-1.12) 0.87 (0.64-1.17) 0.95 (0.73-1.25) 0.70 (0.49-0.95)

KJG 0.64 0.79 (0.57-1.11) 0.85 (0.55-1.14) 0.88 (0.61-1.20) 0.73 (0.50-1.05)

KGR 0.75 0.72 (0.51-1.04) 0.62 (0.42-0.89) 0.64 (0.44-0.90) 0.61 (0.40-0.91)

TML 0.86 0.59 (0.41-0.85) 0.64 (0.43-0.90) 0.80 (0.56-1.15) 0.83 (0.59-1.15)

KP 0.90 1.06 (0.79-1.37) 0.95 (0.72-1.25) 0.95 (0.71-1.26) 0.98 (0.74-1.33)

SMJ 0.93 0.78 (0.57-1.07) 0.70 (0.51-0.97) 0.69 (0.49-0.95) 0.82 (0.60-1.10)

BP 0.76 0.69 (0.50-0.94) 0.87 (0.65-1.14) 0.69 (0.47-0.97) 0.79 (0.58-1.06)

TW 0.55 0.72 (0.51-0.98) 0.67 (0.47-0.93) 0.76 (0.53-1.03) 0.65 (0.43-0.93)

MRI 0.69 0.89 (0.62-1.25) 0.65 (0.42-0.96) 0.62 (0.43-0.89) 0.50 (0.32-0.73)

KLM 0.87 0.83 (0.62-1.11) 0.69 (0.50-0.94) 0.75 (0.56-1.00) 0.79 (0.58-1.04)

SDG 0.71 0.61 (0.42-0.86) 0.61 (0.44-0.85) 0.65 (0.46-0.90) 0.57 (0.41-0.81)

SB 0.74 0.88 (0.64-1.17) 0.75 (0.54-1.01) 0.87 (0.65-1.14) 0.78 (0.56-1.04)

DKS 1.04 0.76 (0.55-1.02) 0.74 (0.52-1.01) 0.76 (0.52-1.06) 0.83 (0.61-1.14)

SI 0.72 0.77 (0.56-1.07) 0.73 (0.52-1.01) 0.78 (0.55-1.10) 0.78 (0.55-1.11)

SBL 0.73 0.74 (0.53-1.03) 0.63 (0.45-0.90) 0.92 (0.65-1.28) 0.67 (0.48-0.97)

AMP 0.89 0.92 (0.71-1.20) 0.90 (0.69-1.17) 0.89 (0.69-1.15) 0.9 (0.69-1.17)

LIK 0.14 0.19 (0.10-0.45) 0.27 (0.14-0.57) 0.58 (0.30-1.08) 0.28 (0.11-0.57)

LKW - - 0.96 (0.71-1.25) 0.74 (0.48-1.08) 0.84 (0.61-1.12)

BM - - 0.54 (0.36-0.79) 0.58 (0.41-0.79) 0.33 (0.22-0.48)

SLR - - 0.98 (0.76-1.26) 0.71 (0.51-0.99) 0.80 (0.59-1.04)

PD - - 0.60 (0.40-0.92) 0.74 (0.51-1.05) 0.75 (0.48-1.08)

KKR - - 0.68 (0.47-0.96) 0.64 (046-0.88) 0.40 (0.27-0.60)

91

SGT - - 0.74 (0.51-1.03) 0.73 (0.54-0.99) 0.50 (0.35-0.71)

TM - - 0.76 (0.49-1.13) 0.68 (0.46-0.96) 0.60 (0.41-0.84)

KEM - - 0.30 (0.17-0.46) 0.44 (0.28-0.65) 0.67 (0.48-0.94)

KLP - - 0 (0) 0.53 (0.31-0.83) 0.65 (0.43-0.96)

LAB - - 0.87 (0.64-1.16) 0.94 (0.72-1.23) 0.83 (0.64-1.06)

KEN - - 0.55 (0.39-0.77) 0.41 (0.25-0.63) 0.33 (0.20-0.51)

BIN - - 1.15 (0.84-1.51) 0.6 (0.40-0.87) 0.60 (0.42-0.87)

LD - - 0.68 (0.5-0.9) 0.77 (0.54-1.06) 0.90 (0.67-1.17)

Total MOH 0.72 (0.51-1.00)

0.69 (0.48-0.95)

UMMC - - 0.83 (0.60-1.14)

0.65 (0.44-0.91)

0.65 (0.44-0.90)

SJMC 0.36 0.44 (0.24-0.89)

0.44 (0.23-0.85)

0.28 (0.14-0.68)

0.22 (0.11-0.59)

The pooled standardized mortality ratio for MOH ICUs in 2014 was 0.69 (95% CI 0.48 – 0.95). It is observed that the SMR has been steadily decreasing over the years. However, risk-adjusted severity scoring systems are known to drift in calibration over time and this may result in lower SMR over the years.

92

SECTION F:

QUALITY IMPROVEMENT ACTIVITIES

93

VENTILATOR CARE BUNDLE

Table 43 : Ventilator Care Bundle Compliance, by individual hospital, 2010 - 2014 Hospital

% Compliance Year

2010 2011 2012 2013 2014

AS 91.75 95.85 97.6 100.0 100.00

PP 99.05 94.79 92.8

93.5 92.74

IPH 97.67 98.65 98.5 97.8 97.02

KL 90.93 94.70 96.6 96.2 96.19

SLG 88.18 96.38 96.8 96.1 96.20

KLG 89.14 94.46 95.3 97.4 99.07

SBN 100.00 100.00 99.4 100.0 100.00

MLK - 98.36 100 99.3 99.23

JB 99.30 98.97 99.2 99.5 99.42

KTN 96.57 98.13 98.4 100.0 99.32

KT 100.00 98.71 97.9 100.0 100.00

KB 99.13 100.00 100 100.0 100.00

KCH 85.14 92.08 97.2 96.1 96.41

KK 76.79 72.41 100 98.5 99.7

SP 98.13 100.00 100 100.0 92.96

PJY 100.00 100.00 100 100.0 100.00

MUR 98.29 100.00 100 99.1 100.00

TI 92.15 91.04 100 100.0 100.00

TPG 94.57 98.11 98.4 97.9 100.00

SJ 97.05 98.70 100 100.0 100.00

KJG 96.96 100.00 100 100.0 100.00

KGR 96.49 100.00 100 100.0 100.00

TML 90.95 97.60 97.2 99.0 96.82

KP 90.24 95.31 98.1 100.0 99.28

SMJ - 96.15 98.5 100.0 100.00

BP 96.52 95.31 96.7 99.5 97.55

TW 100.00 94.44 100 100.0 100.00

MRI 96.90 87.61 100 100.0 100.00

KLM 90.00 86.77 93.9 94.7 96.85

SDG 86.25 96.04 100 100.0 100.00

SB - - 95.9 97.2 100.00

DKS - - 100 100.0 100.00

SI - - 91.3 92.9 90.00

SBL - - 99.8 100.0 98.97

AMP - - 95.0 94.4 93.62

LIK - - 100 100.0 100.00

UMMC 100.0 100.00

LKW - - 74.2 90.4 100.00

BM - - 100 100.0 97.85

94

SLR - - 92.0 89.4 93.33

PD - - 100 100.0 100.00

KKR - - 100 100.0 100.00

SGT - - 100 91.7 100.00

TM 100.0 100.00

KEM - - 100 100.0 100.00

LAB - - 100 100.0 100.00

KEN - - 100 100.0 100.00

BIN - - 97.6 95.7 100.00

LD - - 100 98.8 100.00

Total 94.13 96.00 97.5 98.2 99.05

The overall VCB compliance rate for 2014 was 99%. VCB compliance is one of the key performance indicators for the Anaesthesia program in MOH. All centres had VCB compliance rates above 85%, which is the target set for this indicator. Figure 28 : Ventilator care bundle compliance and ventilator-associated pneumonia rates, 2007 – 2014

3.6

10.1 6.8

15.413.5

11.6

7.2

5.4

88.390.6

99.196.0 97.582.4

93.898.1

0

2

4

6

8

10

12

14

16

18

20

2007 2008 2009 2010 2011 2012 2013 2014

Year

VA

P p

er 1

00

0 v

enti

lato

r d

ay

s

..

....

...

0

10

20

30

40

50

60

70

80

90

100

VC

B c

om

pli

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.

....

....

.

VAP VCB

95

CENTRAL VENOUS CATHETER (CVC) CARE BUNDLE

Central venous catheter (CVC) care bundle was initiated in ICUs in MOH hospitals in 2008. This evidence-based practice has been implemented in many units worldwide following landmark studies that demonstrated substantial reduction in CVC-BSI [20], [21].

In the NAICU Report 2007, 66.2% of ICU admissions had central venous catheters in-situ. The incidence of CVC-BSI can be used as a measure of the safety of clinical practice processes within an ICU. CVC care bundle compliance rate and incidence of CVC-BSI are monitored in ICUs in MOH hospitals since October 2012. Measurement of CVC-BSI as a performance indicator may pose some problems. The clinical decision to obtain blood cultures directly impacts CVC-BSI rates. ICUs that obtain more blood cultures will inevitably document more CVC-BSI. In addition, the definition of CVC-BSI stipulates absence of other sources of infection to explain positive blood cultures. The degree to which an alternate source of infection could explain a positive blood culture, however, also involves subjective judgment. The denominator used in measurement of CVC-BSI is catheter-days. The catheter-day denominator adjusts for the number of patients with catheters when CVC-BSI rates are compared between units. It is also important to realise that unless the catheter-day denominator for the surveillance period is large, the standard error of an individual rate measurement is high. The need for placement of CVC is dependent on patient disease severity. However, the use of catheter-days does not adjust fully for the difference of patient case mix. Catheter utilisation ratio can be measured to overcome this problem. It is defined as the ratio of the number of CVC-days divided by the number of patient days during a specific surveillance period. Catheter utilisation ratio varies by type of ICU due to patient case mix. It is dependent on patient disease severity, which affects the need to insert the catheter. It is also a reflection on the catheter removal practice or policy in the unit. Table 44 : Catheter Utilisation Ratio, Central Venous Catheter Care Bundle

Compliance and incidence of central venous catheter-related blood stream infection (CVC-BSI), by individual hospital 2013 – 2014

Hospitals Central Venous Catheter

utilisation ratio

CVC care bundle compliance Incidence of CVC-BSI per 1000 catheter days

2013 2014 2013 2014 2013 2014

AS 0.46 0.57 100.0 100.0 0.0 0.0

PP 0.80 0.62 100.0 100.0 2.6 3.5

IPH 0.48 0.46 95.7 90.3 0.3 0.0

KL 0.49 0.46 100.0 100.0 1.5 0.2

SLG 0.91 0.86 90.8 92.1 0.0 0.0

KLG 0.27 0.27 100.0 100.0 0.0 0.0

SBN 0.42 0.52 99.5 100.0 0.9 0.7

MLK 0.62 0.42 99.1 93.8 0.0 0.0

JB 0.32 0.44 96.3 93.8 16.4 11.3

KTN 1.23 1.29 100.0 100.0 0.0 0.0

KT 0.54 0.67 100.0 100.0 0.3 0.3

96

KB 0.73 0.56 100.0 97.5 0.4 0.3

KCH 0.78 0.79 100.0 100.0 0.0 0.0

KK 0.71 0.57 95.1 97.0 0.2 0.0

SP 1.54 0.84 100.0 100.0 0.0 0.0

PJY 0.71 0.74 100.0 100.0 0.7 0.5

MUR 0.36 0.41 100.0 100.0 0.0 0.0

TI 0.75 0.21 100.0 100.0 0.0 0.0

TPG 0.53 0.55 100.0 100.0 0.0 0.0

SJ 0.77 1.14 100.0 100.0 0.0 1.0

KJG 0.34 0.35 100.0 100.0 0.0 0.0

KGR 0.80 0.62 100.0 100.0 0.0 0.0

TML 0.95 0.74 100.0 100.0 0.4 0.0

KP 0.61 0.52 100.0 97.0 0.0 0.0

SMJ 0.54 0.72 100.0 100.0 2.7 0.0

BP 0.46 0.55 91.1 93.3 2.1 0.0

TW 0.53 0.42 86.8 96.1 0.0 0.0

MRI 0.33 0.36 100.0 100.0 0.0 0.0

KLM 0.93 0.87 95.5 95.4 0.0 0.0

SDG 0.41 0.70 100.0 100.0 0.0 0.0

SB 0.89 1.05 92.9 100.0 0.0 0.3

DKS 0.58 0.40 100.0 100.0 0.0 0.0

SI 0.80 0.67 97.1 95.5 0.0 0.0

SBL 0.87 0.89 100.0 100.0 0.4 0.9

AMP 0.92 0.84 82.4 86.6 0.0 0.0

LIK 0.36 0.38 100.0 100.0 0.0 0.0

LKW 0.73 0.26 100.0 100.0 0.0 0.0

BM 0.80 0.57 93.1 96.9 0.0 0.0

SLR 1.00 1.20 100.0 100.0 0.0 0.0

PD 0.31 0.36 100.0 100.0 0.0 0.0

KKR 0.59 0.60 99.1 100.0 1.2 0.0

SGT 0.85 1.06 85.0 90.1 2.2 0.0

TM 0.64 0.52 77.6 100.0 0.0 0.0

KEM 0.16 0.74 100.0 100.0 0.0 0.0

KLP 0.72 1.37 100.0 100.0 0.0 0.0

LAB 0.50 0.64 100.0 100.0 0.0 0.0

KEN 0.08 0.63 100.0 100.0 0.0 0.0

BIN 0.60 0.39 100.0 100.0 0.0 0.0

LD 0.70 0.60 100.0 100.0 0.0 0.0

MOH

Hospitals

0.64 0.63 97.5 98.4 0.8 0.7

SJMC NA NA NA NA NA NA

UMMC 0.39 0.64 100.0 100.0 0.0 0.4

97

Figure 29 : Catheter Utilisation Ratio, Central Venous Catheter Care Bundle Compliance and incidence of central venous catheter-related blood stream infection (CVC-BSI), by hospital 2014

0

20

40

60

80

100

120

AS PP IPH KL SLG KLGSBNMLK JB KTN KT KB KCH KK SP PJY MUR TI TPG SJ KJGKGRTML KP SMJ BP TW MRIKLMSDG SB DKS SI SBLAMP LIKLKW BM SLR PD KKRSGT TM KEMKLPLABKENBIN LD

CV

C C

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om

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0.2

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CVC Care Bundle Compliance CVC-BSI CVC Utilisation Ratio

National Healthcare Safety Network (NHSN) report, data summary for 2013 [23]

Types of ICU

Catheter utilisation ratio

CVC-BSI per 1000 catheter days

Pooled mean

Percentile

10th 25th 50th 75th 90th

Mixed medical/ surgical > 15 beds

0.49

0.8

0.0

0.0

0.6

1.2

2.0

Mixed medical/ surgical < 15 beds

0.37

0.8

0.0

0.0

0.0

1.0

2.4

Neurosurgical 0.43 0.9 0.0 0.0 0.7 1.4 2.2

Surgical 0.55 0.9 0.0 0.0 0.7 1.4 2.5

Trauma 0.53 1.4 0.0 0.5 1.2 2.1 3.4

98

Table 45 : Bacteriological cultures in CVC-BSI, 2013 - 2014

Organisms 2013 n (%)

2014 n (%)

Klebsiella spp. MRO Non-MRO

25 (34.2) 8

17

30 (39.0) 23 7

Acinetobacter spp. MRO Non-MRO

12 (16.4) 5 7

20 (26.0) 18 2

Pseudomonas aeruginosa MRO Non-MRO

15 (20.5) 0

15

14 (18.2) 2 12

Enterobacter spp. MRO Non- MRO

0 (0.0) 0 0

6 (7.8) 3 3

Stenotrophomonas maltophilia

3 (4.1) 0 (0)

Other gram negative bacteria MRO Non-MRO

5 (6.8) 2 3

1 (1.3) 0 1

Staphylococcus aureus

MRSA MSSA

7 (9.6) 7 0

3 (3.9) 2 1

Coagulase negative Staphylococcus

Methicillin resistant Methicillin sensitive

3 (4.1) 2 1

1 (1.3) 1 0

Enterococcus faecium

0 (0) 1 (1.3)

Fungal

3 (4.1) 1 (1.3)

Total 73 (100.0) 77 (100)

The mean compliance rate to CVC care bundle in MOH ICUs in 2014 was 98.4%. The incidence of CVC-BSI was 0.7 per 1000 catheter days and it was comparable when benchmarked with that of US National Healthcare Safety Network (NHSN) [23]; as shown in the table above. However, there was a high possibility of under diagnosis and under reporting in many MOH ICUs. The pooled catheter utilization ratio was 0.63, which was higher than the benchmark. Gram-negative organisms accounted for 92% of causative organisms for CVC-BSI in 2014 in MOH ICUs. The predominant organisms isolated were Klebsiella pneumonia followed by Acinetobacter sp. and Pseudomonas aeruginosa. Majority of CRBSIs are associated with CVCs, and in prospective studies, the relative risk for CRBSI is up to 64 times greater with CVCs than with peripheral venous catheters.

99

The risk of CRBSI is considerably higher in the ICU population than in the non-ICU population. One of the main reasons for this was the frequent insertion of multiple catheters. Moreover the catheters may have been placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods. Meta-analytical study done at the Johns Hopkins University showed that bloodstream infections were the third leading cause of hospital-acquired infections. These infections have an attributable mortality rate of 12% to 25%. Individuals counteract 250,000 bloodstream infections each year in the United States and over 80,000 of these appeared in ICUs. These infections were associated with increased length of hospital stay from 10 to 20 days and increased in the cost of care [25]. 60% of CRBSIs were caused by micro-organisms from the patient's skin. 64% of the pathogens causing CRBSI were gram-positive and 36% were gram-negative. In a recent meta-analysis of CRBSIs, gram-positive cocci constituted 27% of isolates and gram-negative bacilli contributed 56%. The proportion of gram-negative CRBSI was much higher than that reported in western hospitals [22]. Pronovost’s Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety and Quality Keystone ICU project is one of the most successful recent collaborative efforts to reduce CRBSIs. The Keystone Project involved the contribution and analysis of data from 103 ICUs in 67 hospitals. These hospitals implemented five evidence-based procedures (hand washing, use of full-barrier precautions during CVC insertion, skin cleaning with chlorhexidine, avoiding the use of the femoral site and removal of unnecessary catheters) and were able to reduce the median rate of CRBSI infections per 1000 catheter-days from 2.7 infections at baseline to 0 infection at 3 months after implementation of the study intervention (p≤0.002) [21].

In the UK, CRBSI accounts for 10% to 20% of hospital-acquired infections and is associated with both increased ICU stay and mortality [21].

100

EARLY MOBILITY IN ICU

A high proportion of patients who survive intensive care suffer from significant physical disabilities secondary to neuromuscular weakness from critical illness, prolonged bed rest, and immobility. Evidence suggests that early mobilisation in mechanically ventilated patients mitigates the physical, cognitive and psychological complications of critical illness [26]. Early mobilisation has also been shown to decrease the duration of mechanical ventilation and hospital length of stay [27], [28]. Early mobility therapy is a quality improvement initiative introduced in the ICUs in MOH hospitals in the second half of the year 2013. This is a multi-disciplinary team effort involving the clinicians, nurses and physiotherapists to ensure that early mobility becomes a routine part of care for all patients admitted to the intensive care unit. The Early Mobility Protocol consists of 4 levels of physical activity and progression from one level to another depends on the conscious state and functional ability of the patient. Activities in this protocol include body positioning, passive and active range of limb motions, sitting to walking. Compliance to the protocol is calculated as the percent of actual number of activities performed against the expected to be performed for the highest level of mobility for all patients in the ICU. In 2014, there were 40 hospitals that reported their compliance rate to the Early Mobility Protocol. The compliance rate ranged from 30.6% to 100%, with an average of 75.5%. Some of the barriers identified to the implementation of the protocol included concerns on safety of mobilisation of ventilated patients, lack of resources (both staff and equipment) and excessive sedation and delirium. 9 hospitals (SLY, TW, LGW, BM, SGT, TM, KEM, KLP, KEN) did not report their compliance rate to the protocol in 2014.

101

Figure 30 : Compliance to Early Mobility in ICU protocol, by hospital 2014

30.630.631.1

32.833.1

40.643

45.546.3

50.85353

54.5

62.262.2

68.971.3

7373.273.474

79.379.4

81.382.7

84.785.7

87.59394

100100

56.758.4

77.878.879

96.596.698.4

0 20 40 60 80 100 120

KTNSP

KCHSDGLIK

TIKPAS

BINKTKB

MLKAMPSBN

MURPD

TPGKL

KLMSJ

SBLSMJ

SISLRMRIKJG

JBBP

KKRKLGPJY

DKS IPH

LDSB

LABTML

KKPP

KGR

Compliance to Early Mobility protocol (%)

102

SECTION G:

REPORT ON

DENGUE INFECTION IN MOH ICUs

2010 - 2014

103

Report on patients with dengue infection who were admitted to the intensive care units in the Ministry of Health hospitals from 2010 - 2014 In 2014, the number of dengue cases reported by the Ministry of Health increased by 151% from 43,346 in 2013 to 108,698 in 2014 [19] [24]. The number of dengue cases in 2012, 2011 and 2010 were 21,900, 19,884 and 46,171 respectively [16] [17] [18]. Admissions with dengue infection to ICU had increased from 3.6% in 2010 to 9.0% in 2014. In 2014, dengue infection was the most common diagnosis leading to ICU admission. Demographics for the patients who were admitted to ICU had been fairly consistent over the last 5 years, except for duration of mechanical ventilation; ICU and hospital stay which had increased in 2014 as compared to previous years. The crude in-hospital mortality was higher, 7.1% in 2014 compared to 5.9% in 2013. The SMR was also higher, 0.57 in 2014 compared to 0.5 in 2013. The majority of patients admitted to ICU with dengue infection were young, with a median age of 34.6 years in 2014. The median interval from hospital to ICU admission was short, being further shortened to 9.6 hours compared to 12 hours in the previous years. The median length of ICU stay for dengue patients was longer than that of all ICU admissions from the 51 participating ICUs in 2014 (2.8 days compared to 2.5 days). The median length of hospital stay for dengue admissions was shorter compared with that of all ICU admissions (7.1 days compared to 8.7 days). The median length of mechanical ventilation for dengue admissions was 5.0 days which was longer than their median length of ICU stay of 2.8 days. This could be explained by the fact that only 12.1% dengue patients were ventilated. Patients with dengue infection had a much lower SAPS II score on ICU admission compared with the rest of the ICU admissions (mean SAPS II score of 18.6 vs. 36.3). Haematological failure remained the main organ failure on ICU admission over the past 5 years. 23% of the patients had associated co-morbid diseases.

104

Table 46 : General comparison for Dengue infection MOH ICUs 2010 – 2014

Dengue Infection

2010 n = 1643

Dengue Infection

2011 n = 798

Dengue Infection

2012 n = 906

Dengue Infection

2013 n=1550

Dengue Infection

2014 n=3261

Age, years median (IQR)

28.8 (22.5 – 47.3)

29.5 (21.0 – 44.1)

32.8 (21.5-41.8)

31.3 (21.7-46.1)

34.6 (22.0-45.4)

Interval from hospital to ICU admission, days median (IQR)

Not available 0.5 (0.1 – 1.3)

0.5 (0.1-1.3)

0.5 (0.1-1.4)

0.4 (0.1-1.2)

Length of ICU stay, days median (IQR)

1.9 (1.9 – 9.6)

2.0 (1.3 – 3.0)

1.9 (1.2-2.7)

1.9 (1.3-2.9)

2.8 (1.3-3.1)

Length of hospital stay, days median (IQR)

5.5 (3.4 – 17.5)

5.8 (4.1 – 8.3)

5.2 (3.9-7.2)

5.3 (3.9-7.2)

7.1 (3.8-7.2)

Length of mechanical ventilation, days median (IQR)

3.8 (1.4 – 7.2)

3.6 (1.6 - 7.9)

4.2 (1.0-5.0)

2.9 (1.2-6.2)

5.0 (1.5-6.5)

Total SAPS II score, mean +/-SD Median (IQR)

19.0 + 14.1

19.6 + 16.0

17.4 + 13.0

18.6 + 13.2

18.6 + 15.0

15.0 (10.0-23.0)

% Invasive mechanical ventilation

18.6 13.8 9.5 11.2% 12.1

% Co-morbid diseases 18.1 22.3 18.3 25 22.9

Main organ failure %

Without organ failure

32.2 27.3 35.2 36.3 32.4

Respiratory failure

4.7 3.0 3.3 2.9 5.9

Cardiovascular failure

7.1 7.2 6.9 6.1 6.0

Neurological failure

0.6 0.4 0.1 0.7 0.4

Renal failure 0.9 0.7 0.8 1.1 1.2

Hepatic failure 0.4 0.1 0.1 0.3 0.4

Haematological failure

54.0 40.9 53.4 52.5 53.6

SMR (95% CI) 0.75 (0.42-1.20) 0.50 (0.26 – 0.86) 0.51 (0.26 - 0.94) 0.50 (0.28-0.95) 0.57 (0.33-1.05)

105

Table 47 : Dengue infection by individual hospital and crude all-cause in-hospital mortality 2010-2014

Hospital

Year

2010 2011 2012 2013 2014

ICU admission

n (%)

All-cause In

hospital mortality

n (%)

ICU admission

n (%)

All-cause In-

hospital mortality

n (%)

ICU admission

n (%)

All-cause In-

hospital mortality

n (%)

ICU admission

n(%)

All-cause In-

hospital mortality

n(%)

ICU admission

n(%)

All-cause In-

hospital mortality

n(%)

AS 10 (0.6) 0 (0) 14 (1.8) 0 (0.0) 20 (2.2) 0 (0.0) 18 1 (5.6) 9 (0.3) 1 (11.1)

PP 56 (3.4) 2 (3.6) 73 (9.1) 1 (1.4) 14 (1.5) 1 (7.1) 53 5 (9.4) 77 (2.4) 10 (13.0)

IPH 78 (4.7) 6 (7.7) 26 (3.2) 3 (11.5) 18 (2.0) 2 (11.1) 57 3 (5.3) 87 (2.7) 9 (10.3)

KL 165 (10.0) 5 (3.0) 71 (8.9) 2 (2.8) 127 (14.0) 2 (1.6) 141 4 (2.8) 429 (13.2) 23 (5.4)

SLG 98 (6.0) 5 (3.0) 40 (5.0) 1 (2.5) 19 (2.1) 0 (0.0) 76 2 (2.6) 196 (6.0) 12 (6.1)

KLG 164 (10.0) 16 (9.8) 98 (12.3) 6 (6.1) 186 (20.5) 10 (5.4) 190 9 (4.8) 456 (14.0) 34 (7.5)

SBN 34 (2.1) 5 (14.7) 15 (1.9) 3 (20.0) 11 (1.2) 1 (9.1) 24 1 (4.8) 40 (1.2) 5 (12.5)

MLK 256 (15.6) 18 (7.0) 48 (6.0) 4 (8.3) 38 (4.2) 3 (7.9) 212 14 (6.6) 123 (3.8) 7 (5.7)

JB 84 (5.1) 7 (8.3) 22 (2.8) 3 (13.6) 23 (2.5) 2 (8.6) 83 17 (20.5) 75 (2.3) 14 (18.7)

KTN 25 (1.5) 2 (8.0) 11 (1.4) 1 (9.1) 3 (0.3) 0 (0.0) 23 2 (8.6) 26 (0.8) 2 (7.7)

KT 13 (0.8) 0 (0.0) 30 (3.8) 4 (13.3) 24 (2.6) 1 (4.2) 19 1 (5.3) 52 (1.6) 4 (7.7)

KB 36 (2.2) 11 (30.6) 13 (1.6) 1 (7.7) 3 (0.3) 0 (0.0) 25 2 (8.0) 286 (8.8) 20 (7.0)

KCH 22 (1.3) 8 (36.4) 10 (1.3) 1 (10.0) 13 (1.4) 1 (7.7) 25 3 (12.0) 31 (1.0) 2 (6.5)

KK 17 (1.0) 4 (23.5) 19 (2.4) 0 (0.0) 12 (1.3) 0 (0.0) 23 2 (8.7) 31 (1.0) 1 (3.2)

SP 6 (0.4) 2 (33.3) 5 (0.6) 0 (0.0) 11 (1.2) 0 (0.0) 21 1 (4.8) 42 (1.3) 8 (19.0)

PJY 10 (0.6) 1 (10.0) 11 (1.4) 1 (9.1) 10 (1.1) 1 (10.0) 29 1 (3.4) 56 (1.7) 4 (7.1)

MUR 52 (3.2) 0 (0.0) 2 (0.3) 0 (0.0) 4 (0.4) 0 (0.0) 15 1 (6.7) 9 (0.3) 0 (0.0)

TI 2 (0.1) 0 (0.0) 6 (0.8) 0 (0.0) 4 (0.4) 1 (25.0) 6 0 (0.0) 5 (0.2) 1 (20.0)

TPG 8 (0.5) 2 (25.0) 26 (3.3) 2 (7.7) 43 (4.7) 4 (9.5) 32 1 (3.1) 52 (1.6) 3 (5.8)

SJ - - 3 (0.4) 0 (0.0) 1 (0.1) 0 (0.0) 5 0 (0.0) 6 (0.2) 0 (0.0)

KJG 53 (3.2) 5 (9.4) 17 (2.1) 2 (11.8) 23 (2.5) 1 (4.3) 27 0 (0.0) 55 (1.7) 9 (16.4)

KGR 1 (0.1) 0 (0.0) 1 (0.1) 0 (0.0) 6 (0.7) 1 (16.7) 11 1 (9.1) 14 (0.4) 0 (0.0)

SJMC - - - - 54 (6.0) 0 (0.0) - - - -

TML 47 (2.9) 3 (6.4) 28 (3.5) 3 (10.7) 8 (0.9) 0 (0.0) 15 1 (6.7) 90 (2.8) 6 (6.7)

KP 3 (0.2) 2 (66.7) 3 (0.4) 1 (33.3) - - 1 0 (0.0) 21 (0.6) 1 (4.8)

SMJ 17 (1.0) 1 (5.9) 7 (0.9) 1 (14.3) 13 (1.4) 4 (30.8) 5 0 (0.0) 11 (0.3) 1 (9.1)

BP 16 (1.0) 2 (12.5) 9 (1.1) 0 (0.0) 6 (0.7) 0 (0.0) 21 2 (9.5) 14 (0.4) 1 (7.1)

TW 2 (0.1) 1 (50.0) 2 (0.3) 0 (0.0) 9 (1.0) 0 (0.0) 37 2 (5.4) 50 (1.5) 1 (2.0)

MRI 7 (0.4) 1 (14.3) - - 5 (0.6) 3 (60.0) 16 1 (6.2) 15 (0.5) 1 (6.7)

KLM 6 (0.4) 1 (16.7) 8 (1.0) 1 (12.5) 9 (1.0) 1 (11.1) 4 1 (25.0) 20 (0.6) 2 (10.0)

SDG 97 (5.9) 15 (15.5) 50 (6.3) 6 (12.0) 33 (3.6) 0 (0.0) 63 6 (9.5) 158 (4.8) 9 (5.7)

SB 38 (2.3) 10 (26.3) 1 (0.1) 0 (0.0) 9 (1.0) 1 (11.1) 8 1 (12.5) 13 (0.4) 2 (15.4)

DKS 3 (0.2) 1 (33.3) 19 (2.4) 2 (10.5) 5 (0.6) 0 (0.0) 15 1 (6.7) 15 (0.5) 1 (6.7)

SI 15 (0.9) 2 (13.3) 24 (3.0) 3 (12.5) 23 (2.5) 3 (13.0) 96 1 (1.0) 119 (3.6) 8 (6.7)

SBL 164 (10.0) 11 (6.7) 62 (7.8) 3 (4.8) 95 (10.5) 4 (4.2) 74 3 (4.1) 451 (13.8) 24 (5.3)

AMP 36 (2.2) 1 (2.8) 19 (2.4) 0 (0.0) 4 (0.4) 2 (50.0) 12 1 (8.3) 38 (1.2) 3 (7.9)

LIK 1 (0.1) 0 (0.0) 5 (0.6) 0 (0.0) 2 (0.2) 0 (0.0) 3 0 (0.0) 2 (0.1) 0 (0.0)

UMMC - - - - 3 (0.3) 0 (0.0) - - - -

106

BM - - - - - - 1 0 (0.0) 3 (0.1) 0 (0.0)

SLR - - - - 2 (0.2) 0 (0.0) 4 0 (0.0) 8 ( 0.2) 0 (0.0)

PD - - - - 4 (0.4) 0 (0.0) 12 0 (0.0) 19 (0.6) 0 (0.0)

KKR - - - - - - 3 0 (0.0) 12 (0.4) 1 (8.3)

SGT - - - - 1 (0.1) 0 (0.0) 1 0 (0.0) 2 (0.1) 1 (50.0)

TM - - - - - - 8 0 (0.0) 5 (0.2) 0 (0.0)

KLP - - - - - - 1 0 (0.0) 3 (0.1) 0 (0.0)

LAB - - - - 1 (0.1) 1 (100.0) 3 0 (0.0) 2 (0.1) 1 (50.0)

KEN - - - - 1 (0.1) 0 (0.0) 9 0 (0.0) 7 (0.2) 0 (0.0)

BIN - - - - 2 (0.2) 1 (50.0) 13 1 (7.7) 6 (0.2) 0 (0.0)

LD - - - - 4 (0.4) 0 (0.0) 13 0 (0.0) 12 (0.4) 1 (8.3)

Total 1643 (100) 150 (9.1) 853 (100) 55 (6.4) 906 (100) 51 (5.6) 1550 92 (5.9) 3261 (100) 233 (7.1)

107

SUMMARY 1. The total number of ICU beds in the 49 MOH participating centres was 637, with a

median bed occupancy of 90.5%. 2. The number of cases analysed for year 2013 was 38,904, an increase of 4% over the

previous year. 3. The percentage of patients denied admission due to the unavailability of ICU beds had

declined from 37% to 30% in the last five years. 4. The average age of patients excluding those below 18 years was 49.7 years. 5. In MOH hospitals, foreigners constituted 7.1% of all ICU admissions. 6. The average lengths of ICU and hospital stay were 4.7 and 14.2 days respectively. 7. In MOH hospitals, 68% of admissions were non-operative patients, an increase of 5% in

the last five years. 8. Direct admission to MOH ICUs from the emergency department had steadily increased

over the past 10 years from 10% in 2005 to 31% in 2014. 9. In MOH ICUs, cardiovascular failure (36%) was the most common organ failure during

the first 24 hours of ICU admission, followed by respiratory (25%), neurological (19%), renal (10%), haematological (9%) and hepatic (1%).

10. Dengue infection, sepsis and head injury were the three most common diagnoses

leading to ICU admission. The in-hospital mortality for this group of patients was 7.1%, 52.8% and 22.2%respectively.

11. During the first 24 hours of ICU admission, 20%, 9% and 15% of patients had severe

sepsis, acute respiratory distress syndrome and acute kidney injury respectively.

12. The average SAPS II score was 36.3, which carries a predicted risk of in-hospital mortality of 30.4%.

13. The average Sequential Organ Failure Assessment (SOFA) score was 6.4 in 2014. 14. 74%of patients in MOH ICUs and 68% of patients in UMMC ICU received invasive

ventilation with an average duration of 4.9 days. 1% of ICU admissions in the private hospital were mechanically ventilated with average duration of 2.9 days.

15. The percentage of patients who received non-invasive ventilation increased from 5.1%

in 2005 to 18.6% in 2014. 16. In MOH hospitals, 14.2% of ICU admissions received renal replacement therapy, with

intermittent haemodialysis being the most common modality of therapy. 17. Among patients who were invasively ventilated, 9.4% had tracheostomy performed,

with the median time from initiation of ventilation to tracheostomy being 9.5 days.

108

18. The decision to withdraw or withhold therapy was made in 35.2% of patients who died in ICU.

19. The incidence of VAP had decreased by more than half from 10.1 to 3.6 per 1000 ventilator days over the last five years.

20. Gram-negative organism accounted for 92% and 97% of causative organisms for VAP in

MOH and UMMC ICUs respectively. Acinetobacter spp., Klebsiella spp., and Pseudomonas spp. remained the 3 most common organisms causing VAP over the last 7 years in MOH ICUs. 58% of organisms causing VAP were multi-drug resistant.

21. The ventilator care bundle compliance rates for MOH hospitals improved from 94% in

2010 to 99% in 2014.

22. The unplanned extubation rate was 0.4 per 100 intubated days in 2014.

23. The mean incidence of pressure ulcers was 6.9, 5.3 and 5.0 per 1000 ICU days in MOH, UMMC and SJMC ICUs respectively.

24. The incidence of central venous catheter-related bloodstream infection in MOH ICUs

was 0.7 per 1000 catheter days in 2014. 25. 92.3%, 6.5% and 1.3% of the organisms isolated for CVC-BSI were gram-negative, gram-

positive and fungal respectively. 26. The predominant organisms causing CVC-BSI were Klebsiella pneumonia followed by

Acinetobacter spp. and Pseudomonas aeruginosa. 27. The crude in-ICU and in-hospital mortality rates for MOH ICUs were 19.0% and 25.7%

respectively. 28. The mean standardised mortality ratio was 0.69 [95%C.I. 0.48–0.95], 0.65 [95%C.I.0.44 –

0.90] and 0.22 [95%C.I. 0.11–0.59] for MOH, UMMC and SJMC ICUs respectively. 29. The average compliance rate to the Early Mobility in ICU protocol was 75.5% in 2014. 30. The average all cause in-hospital mortality rate for patients admitted for dengue

infection in MOH ICUs had increased from 5.9% in 2013 to 7.1% in 2014.

109

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http://www.moh.gov.my/

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